abstract of the dissertation entitled - school of nursing ka man.pdf · constipation refers to...
TRANSCRIPT
i
i
Abstract of the dissertation entitled
An evidence-based guideline of using abdominal massage
to prevent constipation in patients after having hip surgery
Submitted by
Chan Ka Man
for the degree of Master of Nursing
at The University of Hong Kong
in July 2016
Background
Constipation refers to difficult and incomplete defecation over a prolonged
period of time, which is a prevalent health condition affecting individuals at both
genders at any ages. It is also a worldwide health issue; around 2% to 29.5% of
western population suffered from constipation and its complications. In Hong Kong,
up to 14% of the Chinese adults are suffering from different levels of constipation, as
revealed by a population-based telephone survey. The problem is even more serious in
hospital settings that patients with hip fracture are highly susceptible to constipation
(with incidence rate up to 71.7%). Constipation affects patients’ daily activities as
well as their life quality. The increased risk of postoperative complications due to
constipation also leads to longer hospitalization, greater stress on healthcare
professionals, and accounts for large economic burden to society every year.
ii
ii
There are numerous ways to manage constipation, while the most common one is
to use laxative owing to its relatively quick response. As there is growing concern
over the drawback of laxative use in management of constipation, the practice of
abdominal massage is more widely accepted and become more appealing to the
affected individuals. There are available evidences to show that abdominal massage is
useful in the treatment of chronic constipation. However, there is neither existing
systematic review nor local nursing guideline to support the translation of research
evidences into practice for application of abdominal massage to relieve constipation,
meaning that it is necessary to develop an evidence-based guideline that will inform
health care professionals of the management of constipation based on the best
available evidences.
Purposes
This paper aims to conduct a systematic review to evaluate the existing
evidences, to formulate an evidence-based guideline of applying abdominal massage
in prevention of constipation in target settings, assess the implementation potential in
terms of transferability and feasibility, and finally to develop an implementation
strategy and evaluation plan for the guideline.
Methods
Four renowned electronic databases: CINAHL Plus (EBSCOhost), Medline
(EBSCOhost), British nursing index (ProQuest) and Database from Hospital
Authority named eKG (Ovid) were used for electronic searching. Five randomized
controlled trials were identified according to the inclusion and exclusion criteria of
this dissertation. Data were extracted and the quality and validity of the included
studies was evaluated by the qualified appraisal tool: the Scottish Intercollegiate
iii
iii
Guidelines Network (SIGN). All the five studies were graded as high quality and
indicated that abdominal massage is statistically significant in alleviation of
constipation.
Afterward a systematic review was conducted; the best available evidence was
identified in order to develop the proposed guideline. The implementation potential of
the proposed massage therapy in terms of target audience and setting, transferability,
feasibility and cost-benefit ratio was assessed. An evidence-based guideline of using
abdominal massage to prevent constipation in patients after having hip surgery was
then developed. An implementation plan was formulated; communication with
stakeholders, conduction of a one-month pilot test to determine the feasibility of the
innovation, and an evaluation plan to evaluate the effectiveness of the proposed
guideline were included.
Results
An evidence-based guideline with regard to the application of abdominal
massage to prevent constipation was developed; the proposed innovation appeared as
feasible to be applied in the target setting based on the findings of the pilot test, and
the results were further analyzed to provide recommendations for refinement of the
proposed innovation and hence, facilitate the changing process. The examination of
resources, staff acceptability and compliance, as well as the potential benefits to target
population, frontline staff and the health care system were performed during the
evaluation process with the use of questionnaires. The potential benefit of
implementation outweighed its cost as shown in the cost-benefit estimation.
iv
iv
Conclusion
With the application of abdominal massage in patients after having hip surgery,
it is expected that constipation and its associated complications can be minimized so
that patients can enjoy a better quality of life. In view of nursing staff, the stress for
handling constipation can be reduced whereas nurses can possess a higher level of
autonomy and job satisfaction; the health cost can be reduced as fewer resources are
required to spend on managing constipation and its complications.
v
v
An evidence-based guideline of using abdominal massage
to prevent constipation in patients after having hip surgery
by
Chan Ka Man
BNurs (Hon) (HKU), RN (HK)
A dissertation submitted in partial fulfillment of the requirements
for the degree of Master of Nursing
at The University of Hong Kong
July 2016
vi
vi
Declaration
I declare that this dissertation represents my own work, except where due
acknowledgement is made, and that it has not been previously included in a thesis,
dissertation or report submitted to this university or to any other institution for a
degree, diploma or other qualifications.
Signed: ……………………………………………………
Chan Ka Man
July 2016
vii
vii
Acknowledgement
I would like to take this opportunity to express my deepest gratitude to my
supervisor Dr. Joyce Chung, for her enlightenment, guidance and patience throughout
the writing process, and to Dr. Janet Wong, who directed and provided suggestions
that made this dissertation possible.
I am also thankful for the precious learning opportunity provided by the School
of Nursing, the University of Hong Kong. Not only do I expand my interest and
understanding of nursing career, but also learn about the importance of commitment
during the master studies.
Last but not least, I would also like to express my sincere appreciation to my
family and classmates for their endless support and encouragement in the past two
years.
viii
viii
Content
Abstract ........................................................................................................................... i
Declaration .................................................................................................................... vi
Acknowledgement ....................................................................................................... vii
Content ....................................................................................................................... viii
List of Appendices ........................................................................................................ xi
Abbreviations ............................................................................................................... xii
Chapter 1Introduction .................................................................................................... 1
1.1 Background .......................................................................................................... 1
1.2 Affirming the needs .............................................................................................. 3
1.3 Objectives and Significance ................................................................................. 7
1.3.1 Aim and objectives ....................................................................................... 7
1.3.2 Significance ................................................................................................... 7
Chapter 2 Critical Appraisal........................................................................................... 9
2.1 Search and Appraisal strategies............................................................................ 9
2.1.1 Identification of studies ................................................................................. 9
2.1.2 Selection criteria .......................................................................................... 10
2.1.3 Data extraction ............................................................................................. 10
2.1.4 Appraisal strategies ...................................................................................... 11
2.2 Results
2.2.1 Search results ............................................................................................... 12
2.2.2 Overview of the selected articles ................................................................. 12
ix
ix
2.2.3 Study characteristics .................................................................................... 14
2.2.4 Methodological quality of studies ............................................................... 15
2.3 Summary and Synthesis ..................................................................................... 18
2.3.1 Summary ...................................................................................................... 18
2.3.2 Synthesis ...................................................................................................... 19
2.3.3 Implication ................................................................................................... 21
Chapter 3 Translation and Application ........................................................................ 22
3.1 Transferability .................................................................................................... 22
3.1.1 Target setting and population ...................................................................... 22
3.1.2 Transferability of findings .......................................................................... 23
3.1.3 Philosophy of care ....................................................................................... 24
3.1.4 Number of clients to be benefited ............................................................... 25
3.1.5 Implementation and evaluation ................................................................... 25
3.2 Feasibility ........................................................................................................... 26
3.2.1 Organizational climate and administrator support ...................................... 26
3.2.2 Availability of staff, skills and resources .................................................... 27
3.2.3 Autonomy to initiate and terminate the intervention .................................. 28
3.2.4 Friction within organization ........................................................................ 28
3.2.5 Potential for clinical evaluation .................................................................. 28
3.3 Cost-Benefit Ratio .............................................................................................. 29
3.3.1 Potential risk ............................................................................................... 29
3.3.2 Potential benefit .......................................................................................... 29
x
x
3.3.3 Cost Estimation ........................................................................................... 31
Chapter 4 Evidence-based Practice Guideline ............................................................. 33
Chapter 5 Implementation Plan ................................................................................... 37
5.1Communication Plan ........................................................................................... 37
5.1.1 Identification of stakeholders ...................................................................... 37
5.1.2 Communication process .............................................................................. 39
5.1.3 Communication strategies ........................................................................... 40
5.2 Pilot Study Plan .................................................................................................. 41
5.2.1 Setting and duration ..................................................................................... 42
5.2.2 Subject recruitment and sample size ........................................................... 42
5.2.3 Details of the pilot study ............................................................................. 42
5.2.4 Data collection and instrument ................................................................... 43
5.2.5 Evaluation of pilot study.............................................................................. 43
5.3 Evaluation Plan .................................................................................................. 45
5.3.1 Identification of outcomes ........................................................................... 45
5.3.2 Nature and number of clients to be involved ............................................... 46
5.3.3 Time and frequency to take measurements .............................................. 47
5.3.4 Data analysis ............................................................................................. 48
5.3.5 Criteria for considering a practice as effective ......................................... 49
5.4 Conclusion .......................................................................................................... 49
Appendix ...................................................................................................................... 50
Reference……………………………………………………………………………..93
xi
xi
List of Appendices
Appendix 1 Key to evidence statements and grades of recommendations 50
Appendix 2 Table of search strategies 51
Appendix 3 PRISMA 2009 Flow Diagram 52
Appendix 4 Table of Evidence A 53
Appendix 5 Table of Evidence B 54
Appendix 6 Table of Evidence C 55
Appendix 7 Table of Evidence D 56
Appendix 8 Table of Evidence E 57
Appendix 9 Scottish Intercollegiate Guidelines Network (SIGN) Checklist A 58
Appendix 10 Scottish Intercollegiate Guidelines Network (SIGN) Checklist B 61
Appendix 11 Scottish Intercollegiate Guidelines Network (SIGN) Checklist C 64
Appendix 12 Scottish Intercollegiate Guidelines Network (SIGN) Checklist D 67
Appendix 13 Scottish Intercollegiate Guidelines Network (SIGN) Checklist E 70
Appendix 14 Timeline of an evidence-based program to prevent constipation in patients
after having hip surgery
73
Appendix 15 Table showing set-up and operational cost in terms of personnel salary of the
evidence-based abdominal massage therapy
74
Appendix 16 Table showing the cost to be saved from implementation of program per year 75
Appendix 17 Grades of recommendations 76
Appendix 18 Flowchart of the communication plan within the O&T Department 77
Appendix 19 Self-designed patient referral form for abdominal massage 78
Appendix 20 Self-designed nursing assessment form for abdominal massage program 79
Appendix 21(a) SF-12 Health Survey (English version) 80
Appendix 21(b) SF-12 Health Survey (Chinese version) 82
Appendix 22(a) Self-designed questionnaire for patients (English version) 84
Appendix 22(b) Self-designed questionnaire for patients (Chinese version) 86
Appendix 23 Self-designed staff satisfaction survey on the staff training and pilot study 87
Appendix 24 Self-designed audit form for abdominal massage 89
Appendix 25 Self-designed record form for abdominal massage 90
Appendix 26 Self-designed questionnaire for nurses in O&T Department 91
xii
xii
Abbreviations
COS Chief of Service
DOM Department Operational Manager
EBP Evidence-based practice
HA Hospital Authority
HRQoL Health-related quality of life
NS Nurse Specialist
O&T Orthopedics and Traumatology
QoL Quality of life
RCT Randomized controlled trial
RN Registered Nurse
SIGN Scottish Intercollegiate Guidelines Network
SPSS Statistical Package for Social Science
TOE Table of evidence
VAS Visual analogue scale
WM Ward Manager
1
1
CHAPTER 1
INTRODUCTION
1.1 Background
Excretion, being one of the seven characteristics of living things, is the ability of
an organism to get rid of the solid or liquid waste matter from the body (Oxford
Advanced Learner’s English-Chinese Dictionary, 1994, p.499). All living things need
to remove waste from their bodies for their survival; if this waste remains in the body
it could be poisonous. In mammals, the solid product of undigested food is called
feces, where the process of removing feces out of the digestive tract is known as
defecation (Defecation, 2015). Defecation is caused by series of muscular
contractions called peristalsis in the walls of the colon to push the feces toward
the rectum. In humans, defecation commonly takes place in one to two days, while the
frequency varies from individual to individual.
Nevertheless, incomplete and difficult elimination of feces may occur, i.e. a
condition regarded as constipation (Connor, Hunt, Lindley & Adams, 2014).
According to Gary’s study in 2014, constipation refers to “difficulty during defecation
and infrequent bowel movements over a prolonged period of time”, where it affects
individuals at both genders at any ages. Common risk factors for constipation include
inadequate fluid and fiber intake, limited physical exercise, advancing age and a
sedentary occupation (Causes of Constipation, 2014). In order to diagnose
constipation, medical history taking and physical examination are necessary. Patients
have to provide information about diet, medication history, level of physical activity
and bowel status including onset of symptoms, frequency of bowel movements,
2
2
consistency of stools, presence of blood in the stool and bowel habit. On the other
hand, physical examination may include digital rectal exam by using a lubricated,
gloved finger to evaluate the tone of the anal sphincter to detect tenderness, fecal
impaction, or presence of blood (Diagnosing constipation, 2014).
As a matter of fact, constipation is a highly prevalent health problem, accounting
for a large proportion of complaints of gastrointestinal symptoms such as bloating,
abdominal cramps, nausea, decreased appetite and generalized discomfort (Noiesen et
al., 2013). Despite the life threatening complications being rare, chronic and
unmanaged constipation can lead to severe health outcomes such as intestinal
obstruction, anal fissure and incontinence (Noiesen et al., 2013); it also results in
psychological distress and anxiety to individuals that affect their social well-beings
and hence, decrease the quality of life (Doreen, Suzanne, Stanley & Andrea, 2013).
The management also accounts for a large economic burden to society every year
(La m̈a° s, Lindholm, Engstro m̈ & Jacobsson, 2010).
In western countries, 2% to 29.5% of population suffered from constipation and
its associated complications (La m̈a° s, Lindholm, Engstro m̈ & Jacobsson, 2010).
The same study also revealed that 50-75% of nursing home residents in Finland and
the America were diagnosed of constipation with routine usage of laxatives, while up
to 11% of elderly receiving home care also suffered from constipation, implying that
it could be a fundamental care problem. In addition, evidences showed that
constipation affects more in women than men, and its prevalence increases with age,
particularly more severe in adults aged over 65 (Gary, 2014). Constipation, yet being
unpleasant and often recurrent, can be prevented or managed in various ways such as
adequate consumption of fluid and fiber, physical activities, manual evacuation,
3
3
digital stimulation and regular use of laxatives (La m̈a° s, Lindholm, Engstro m̈ &
Jacobsson, 2010). In this way, nurses have an important role in managing constipation
of the patients, particularly by carrying clinical examination and history taking to rule
out the underlying causes (Gary, 2014), and conducting research studies to generate
evidences to improve the current practices.
1.2 Affirming the needs
In the past decade of years, the provision of health care is mainly based on
tradition, expert opinion or health care providers’ preference. With regard to the
growing demand and expectation of quality service, the complexity in nursing
practice increases too and nurses assume a higher level of workload, responsibility,
and initiative for patient outcome (Lopez, 2003). These give rise to the surge of
studies regarding various research problems aimed at providing better patient service,
known as evidence-based practice (EBP). Nowadays, evidence-based practice implies
application of the best available research findings to determine the choice of
healthcare (Carlson, 2015). By reviewing and utilizing up-to-date research findings,
best available empirical evidence can be identified and applied to clinical practice.
Therefore, it is significant to develop an evidence-based protocol or guideline in
clinical setting, as EBP can aid clinical decision-making, optimize patient outcomes
and provide cost-effective high quality care (Taylor, 1998). As a nurse, it is also
important to be more sensitive to new research and technology; nurse should take an
active role in evoking changes and implementing evidence-based recommendations to
improve the current nursing practice through clinical observation, research and
literature review.
4
4
In Hong Kong, a population-based telephone survey revealed that 14% of the
Chinese adults suffering from different levels of constipation based on the Rome II
criteria (Chan et al., 2004). As a matter of fact, the problem of constipation is even
more prevalent and serious in hospital settings, with 79% has been reported,
according to Trads and Pedersen’s study (2015). However, there are always
misconceptions about facts and management of constipation. Being an overlooked
aspect of patient care, constipation is always considered as a boring subject which is
self-limiting and not requiring prompt management (Gary, 2014), indicating that it is
high time to develop an evidence-based guideline to manage constipation in clinical
setting.
I consider the target setting as Department of Orthopedics and Traumatology
(O&T) in one of the acute and busy hospitals in Hong Kong. As a nurse working there
for three years, I noticed that constipation is especially prevalent among patients
undergone surgery. Such an observation is consistent with the findings of a research
study conducted by Trads and Pedersen in 2015, in which the incidence rate of
constipation in patients with hip fracture was up to 71.7%. The same study also
suggested that constipation increased the risk of postoperative complications that
could increase individual suffering and the staff workload. The management for
constipation also accounts for a large economic burden to society every year (La m̈a°
s, Lindholm, Engstro m̈ & Jacobsson, 2010).
Considering the department I am working in, the annual admission rate is quite
steady that is around 1600 cases every year. Based on my clinical observation, up to
40% are those with indication for hip surgery. As discussed by Trads and Pedersen
(2015), this group of patients is more susceptible to constipation owing to a lot of risk
factors including:
5
5
1. Adverse effect of medication: Tramadol (a potent drug commonly used for pain
relief after surgery), is a kind of opioid medication that will induce constipation
(Webster, 2015).
2. Environmental factor: Staying in an unfamiliar place for a prolonged period (from
pre-operation to rehabilitation phase) will lead to change in defecation pattern; for
instance a pre-morbid ambulatory patient may find it difficult to defecate into a
bedpan or commode at bedside.
3. Inadequate fluid and fiber intake: patients are required to keep fasting before the
surgery whereas even diet is resumed postoperatively, their intake and appetite
tends to be fair to poor.
4. Physical immobilization inhibits the peristalsis of intestines.
There are numerous strategies to manage constipation, whereas use of laxatives is
most widespread and is regarded as effective with quick response. However, long
term use of laxatives could result in harmful side effects such as fecal impaction and
reduced sensitivity to the drugs that gain little or no effect (Gary, 2014). The use of
laxatives is very common in the target setting, where around 40% of the patients there
admit for orthopedic hip problems that require surgical intervention. Those patients
would suffer from different level of immobilization from post-injury to postoperative
period, making them more prone to constipation. Due to heavy workload, nurses
seldom ask patients for their choices of treatment or consider other strategies for
management of constipation, despite the fact that use of laxatives, no matter by oral or
per-rectal route, is always declined by young patients. Hence, it is suggested that
nurse should empower patients more by involving them in making decisions about
treatment, as communication between nurse and client is essential to develop
therapeutic trust and rapport (Gary, 2014).
6
6
In view of the disadvantages of using medications to treat constipation,
abdominal massage, as a non-pharmacological method, is introduced and being
appealing to the affected group. In fact, abdominal massage for the management of
constipation was used as early as in 1870, and it was experienced as pleasurable and
safe that the participants felt more comfortable with their bowel function improved
after the treatment (La m̈a° s, Graneheim & Jacobsson, 2010). Most of the research
studies about the use of abdominal massage on managing constipation showed
positive effects in stimulating peristalsis and decrease colonic transit time in
constipated patients, and will be further discussed in Chapter Two of this paper. On
the behalf of patient, application of the massage therapy can be complementary to
medication use, provided that patients usually refuse use of drugs in managing
constipation for fear of the side effects such as cramping over abdomen and increased
dependency on the drug. In this way, the practice of abdominal massage is more
widely accepted, as it is non-invasive and non-pharmacological that could be
self-managed by patients even at home with education provided. Although there are
growing concerns on the application of abdominal massage in managing constipation,
the scientific evidence regarding its effectiveness in the treatment of chronic
constipation is still scarce (Sinclair, 2010). Currently there is no published systematic
review to support the translation of existing evidences into practice; locally no
available nursing guidelines can be found in applying abdominal massage to relieve
constipation, suggesting that more studies regarding the effectiveness of this strategy
are needed.
7
7
1.3 Objectives and Significance
The research question of this proposed study in PICO format is: How effective
the abdominal massage, in comparison to the usual care, in prevention of constipation
among patients after having hip surgery?
1.3.1 Aim and objectives
The aim of the proposed study is to develop an evidence-based guideline to
improve the nursing care so as to prevent constipation among patients after having hip
surgery. The objectives are listed as below:
1. To conduct a systematic review for evaluation of effectiveness of abdominal
massage in management of constipation;
2. To evaluate the quality of studies, and to summarize and synthesize the data;
3. To develop an evidence-based guideline to prevent constipation in patients after
having surgery using abdominal massage;
4. To assess the transferability and feasibility of implementing the massage therapy
in current setting; and
5. To develop implementation strategies and evaluation plan for the evidence-based
guideline.
1.3.2 Significance
As discussed in previous parts, constipation, though preventable, can lead to
severe complications if not identified or not treated properly. However, the
knowledge of health care providers about how to manage constipation is often limited;
potential risks of constipation are usually masked and not being aware due to
relatively low mortality rate (Gary, 2014). Hence, nurses should participate more in
8
8
managing the condition, particularly by performing a detailed history taking and
clinical assessment to investigate the possible underlying causes of constipation. It is
especially important for primary care nurses, as early detection and prevention could
avoid more severe health consequences.
With the implementation of evidence-based practice guideline over the use of
abdominal massage in patients after having hip surgery, the possibility of constipation
is reduced, the symptoms of constipation is relieved and the risk of postoperative
complications is minimized. In patients’ aspect, hospital visit and length of
hospitalization are also reduced and therefore, the quality of life could be enhanced.
For the health care provider, the implementation of an EBP guideline can aid
decision-making on use of alternative strategies to manage constipation in addition to
usual medication, and provide detailed instruction of applying abdominal massage to
constipated patients. As the massage therapy can help to prevent, alleviate
constipation and reduce the likelihood of postoperative complication, the workload
and stress in handling those undesirable health consequences could be minimized. In
addition, the EBP guideline can offer a systematic approach to planning,
implementing and evaluating the nursing practice over management of constipation.
On a more macroscopic view, the quality of service provided can be improved
with the implementation of the proposed EBP guideline; patient’s confidence and
satisfaction toward the hospital service and health care system will be enhanced. In
this way, less healthcare costs and resources on managing constipation and its
complications are anticipated, and therefore health cost will be reduced.
9
9
CHAPTER 2
CRITICAL APPRAISAL
2.1 Search and Appraisal strategies
2.1.1 Identification of studies
Identifying potential and relevant studies is an essential component in
translational nursing research. A three-step search strategy was utilized. To begin with,
an initial electronic search for all available evidences were conducted; four renowned
electronic databases were used which included CINAHL Plus (EBSCOhost), Medline
(EBSCOhost), British nursing index (ProQuest) and Database from Hospital
Authority named eKG (Ovid). In second search, various keywords were identified and
searched across the four included databases in order to obtain potential articles.
Thirdly, a manual search of the listed reference in the identified literatures was
performed so as to obtain additional journals for enrichment of the content of my
study. The titles and abstracts of the searching results were then screened according to
the inclusion and exclusion criteria (as listed below). For those considered to be
potentially relevant, the full-text article was retrieved and reviewed to further look for
its eligibility.
Different keywords were used to conduct searching for articles that relevant to
my research topic, which could be classified into three groups. The first group of
keywords concerned the clinical problem identified, including “constipation” and
“bowel symptom”; the second group of keyword referred to the intervention, and
wording like “abdominal massage” was used; the third group of keywords described
10
10
the characteristic of the study population using word texts as “postoperative” and
“surgery”. Since different authors might use different words with similar meaning to
describe a common idea, those keywords should be searched both individually and in
different combination to ensure more potential articles were yielded. For instance, the
keywords within same group were entered into databases using “or” to include all
possible findings, whereas using “and” between difficult groups of keywords to
narrow down the findings to more specific ones.
2.1.2 Selection criteria
For the inclusion criteria, studies are chosen if they: (1) were randomized
controlled trials (RCTs) in view of higher level of evidence; (2) used language only
English or Chinese to avoid language barrier; (3) evaluated the effect of abdominal
massage in adult patients; (4) assessed the subjects diagnosed with constipation; and
(5) were published in 1995 or for years afterwards to ensure the data obtained was
up-to-date and reliable.
For the exclusion criteria, studies are rejected if they: (1) examined pediatric
population; (2) focus on pharmacological intervention, and (3) did not provide
full-text article.
2.1.3 Data extraction
After reviewing the eligible literature, the data including bibliographic citation,
study type, level of evidence, sample size, subject characteristics, intervention and
control, length of study, outcome measures and effect size were extracted. Since there
were variations in the kinds of outcome measures, statistical pooling and direct
comparison of the outcome findings between different studies was inappropriate.
11
11
Therefore, a table of evidence (TOE) was established using the extracted data to
provide a clear, accessible and comprehensive summary of the selected studies and
hence, allows easier determination of the answer for the research question (i.e. the
effectiveness of abdominal massage in prevention of constipation).
2.1.4 Appraisal strategies
The quality of studies is an essential criterion to determine if the evidences
extracted from literature review is worthwhile utilizing for this dissertation.
The quality of each individual article was assessed and evaluated by using appraisal
tools named Scottish Intercollegiate Guidelines Network (SIGN, 2014). The SIGN
checklist consists of two sections: internal validity and overall assessment of the study,
which is used commonly to determine if the study is of high level of reliability and
validity with minimum bias identified. The following aspects were addressed in the
checklist:
1. Clarity of research question
2. Randomization procedure
3. Allocation concealment
4. Degree of blinding
5. Similarity of intervention and control groups
6. Treatment under investigation
7. Appropriateness of measurement tools
8. Dropout
9. Intention-to-treat analysis
10. Similarity of results between different centers
12
12
After completing the appraisal of the selected articles using SIGN checklist, the
level of evidence was rated according to the evidence statements and grades of
recommendations established by Scottish Intercollegiate Guidelines Network (2014),
from highest grading“1++” to lowest grading “4”, which is shown in Appendix 1.
2.2 Results
2.2.1 Search results
Electronic and manual searching was conducted from 18th
September, 2015 to
22nd
September, 2015. A total of 86 relevant articles were yielded through the four
databases: CINAHL Plus (EBSCOhost), Medline (EBSCOhost), British nursing index
(ProQuest) and eKG (Ovid); an additional 23 articles were retrieved through browsing
Google Scholar. After reviewing the abstract and title of the studies identified,
duplicated studies were removed and only 46 articles left. The remaining articles were
further screened with reference to the inclusion and exclusion criteria, with 5 full-text
articles eligible for this proposed study. However, no extra literature was extracted
from searching reference lists of the eligible studies. A detailed search history and the
search flow diagram are shown in Appendices 2 and 3 respectively.
2.2.2 Overview of the selected articles
There were five studies selected in the searching procedure: (McClurg et al.,
2011; La m̈a°s et al., 2010; La m̈a°s et al., 2009; Emly et al., 1998; Kassolik et al.,
2015). Tables of evidence were established for each independent study, which are
shown in Appendices 4 to 8. Information on the author, study type, level of evidence,
subject characteristics, sample size, intervention and control, length of study, outcome
measures and effect size were listed clearly in the tables.
13
13
In Appendix 4, McClurg et al. (2011) reported a significantly positive effect of
abdominal massage on relieving the symptoms of constipation among patients with
multiple sclerosis, with provision of advices on bowel management as the control. It
was an 8-week study with outcomes measured at 4 weeks post-treatment and at the
end of the study.
Appendix 5 shows an 8-week study conducted to evaluate the change in health
related quality of life (HRQoL) for constipated people and estimate the
cost-effectiveness of massage therapy. Intervention lasted for 7 weeks and data
collected from questionnaire that administered at the end of the study (La m̈a°s et al.,
2010).
In Appendix 6, La m̈a°s et al. (2009) concluded that abdominal massage had
significantly reduced the severity of gastrointestinal symptoms, according to the result
obtained from the 8-week study among constipated people.
In Appendix 7, the study was a cross-over trial among two randomized groups of
profoundly disabled people with constipation aimed to compare the effectiveness of
abdominal massage against laxative therapy in management of constipation. One
group received massage therapy for the first phase and usual laxative therapy in
second phase with one week wash-out period in-between, and vice versa for the other
group being studied. Gastro-intestinal and segmental transit time was used for the
primary outcome measure. Emly et al. (1998) reported that there was not much
difference between the effect of massage and laxative therapy, but both interventions
demonstrate significant effect in relieving constipation.
14
14
In Appendix 8, the aim of study was to determine the effectiveness of massage
based on tensegrity principle in relieving constipation, with classical massage acting
as the control. Although classical massage not the key intervention to be examined,
the results revealed that the classical massage had considerate effects in management
of constipation, which was statistically significant (Kassolik et al., 2015).
2.2.3 Study characteristics
The five selected papers included studies that were carried out in United
Kingdom (McClurg et al., 2011 & Emly et al., 1998), Sweden (La m̈a°s et al., 2009 &
2010) and Poland (Kassolik et al., 2015). They were published between 1998 and
2015 and all of them were randomized control trials. Among them, four of the studies
included an intervention group and a control group to examine the difference between
groups in managing constipation, except the study of Emly et al. (1998) was a
cross-over trial to investigate the effectiveness of two interventions (laxative and
massage) in managing constipation and do comparison. Meanwhile, all studies used
classical massage therapy as an intervention except the study of Kassolik et al. (2015)
that classical massage was used as control for comparison with the massage based on
tensegrity principle.
Two single-centered studies identified were conducted by McClurg et al (2011)
and Emly et al. (1998). For the two studies conducted by La m̈a°s et al. in 2009 and
2010, the recruitment of subjects was via local newspapers, notices at care centers and
nursing homes. The subjects of Kassolik et al.’s study (2015) were recruited from two
university-based primary care centers.
15
15
The sample size of the five studies is similar, ranging from 29 to 50. There was
no significant difference in the demographic characteristics between the intervention
and comparison in the five studies, including age, gender, marital status and history of
laxative use. The mean age of the five studies varied from 42.25 to 63.7. Female
subjects were predominant in all the studies. All the subjects recruited had routine use
of laxative before the studies and suffered from certain degree of physical immobility
due to their co-morbid status. However, there was considerate difference in the degree
of physical mobility among the subjects in study of Emly et al. (1998), varying from
ambulant, partially dependent to totally dependent.
For outcome measurements, various standardized assessment tools were used to
describe the severity of constipation, as reported in studies of McClurg et al (2011)
and La m̈a°s et al. (2009). Another two studies (La m̈a°s et al., 2010 & Kassolik et al.,
2015) used questionnaire to determine the bowel and health statues in terms of the
frequency of bowel movement, experience of bowel symptoms and perceived level of
comfort. On the other hand, Emly et al. (1998) employed a radiographic method to
examine the transit time of stool within the abdomen during the study.
2.2.4 Methodological quality of studies
The quality of each individual article was evaluated according to the appraisal
tools of the SIGN Checklist (See Appendices 9 to 13). All the five studies were ranked
in a higher level in the hierarchy of evidence as they were RCTs. Among them, the
studies conducted by McClurg et al. (2011), La m̈a°s et al. (2009) and Kassolik et al.
(2015) rated higher level as “1+”, whereas the other two studies (La¨ma°s et al., 2010
& Emly et al., 1998) were rated as “1-”. The paper quality was evaluated in the
following aspects:
16
16
i. Clarity of research question
The research questions and objectives were clearly and appropriately addressed
in each of the five studies. A clear conclusion was also stated at the end of the
articles.
ii. Recruitment of subjects
In studies of La m̈a°s et al. in 2009 and 2010, the recruitment of subjects was via
local newspapers, notices at care centers and nursing homes; in study of
McClurg et al. (2011), the recruitment was also volunteer-based, which is known
as non-probability sampling. The self-referring nature of recruitment would
decrease the generalizability and accountability of the research findings.
iii. Allocation of subjects
All the five studies claimed that subjects were randomized to the intervention or
comparison group. In the study of La m̈a°s et al. conducted in 2009 and 2010,
subject allocation was done by block randomization by means of drawing lots.
For McClurg et al.’s study (2011), participants were randomly allocated using a
web-based system. However, the remaining two studies did not mention about
the method of randomization (Emly et al., 1998 & Kassolik et al., 2015).
iv. Allocation concealment
In the study of Emly et al. (1998) and Kassolik et al. (2015), concealment was
mentioned but the method was not described. For the other three studies,
concealment was described in using computerized allocation systems and codes
to differentiation.
17
17
v. Degree of blinding
For the studies carried out by McClurg et al. (2011) and La m̈a°s et al. (2009 &
2010), blinding was not possible due to the nature of the study. The remaining
two studies retained high level of blinding to the subjects, therapists and
analyzers.
vi. Similarity between groups
There was no significant difference in the demographic characteristics between
intervention and comparison group in the five studies in general. However, there
was considerate difference in the physical mobility among the subjects in the
study of Emly et al. (1998), where physical immobility is one of the factors
affecting defecation.
vii. Treatment under investigation
Abdominal massage was regarded as intervention to manage constipation in four
of the studies, except in one that it was used as control to compare the effect with
other intervention (Kassolik et al., 2015). In general, the results of the studies
were considered to be the effects of intervention because there was only one
intervention in the studies. However, there were two interventions (laxative and
massage therapy) in Emly et al.’s cross-over trial study (1998). Although there
was one-week period of wash-out to avoid the bring-about effect of the first
intervention, it is difficult to determine if the length of wash-out period was
enough.
18
18
viii. Appropriateness of measurement tools
Standard and reliable measurement tools were used in studies (McClurg et al.,
2011 & La m̈a°s et al., 2009) that generated data of higher degree of objectivity.
ix. Dropout
The dropout rate is insignificant, ranging from the lowest 3.125% (Emly et al.,
1998) to the highest 13.8% in studies of La m̈a°s et al. (2009 & 2010). In fact, up
to 20% dropout rate is still regarded as acceptable.
x. Intention-to-treat analysis
In the five studies, the method of intention-to-treat analysis was used with all
participants included in the data analysis despite the loss of subjects during the
study.
xi. Similarity of results between different centers
Only three papers indicated that the studies took place in multi-centers (La m̈a°s
et al., 2009 & 2010 ; Kassolik et al., 2015) that the results were found to be
similar between different centers. As a matter of fact, the results synthesized
from a multi-center study retain a higher level of generalizabilty.
2.3 Summary and Synthesis
2.3.1 Summary
For the five studies selected for data extraction and synthesis, the research
question and study type are clearly stated. The effect of abdominal massage on
management of constipation was examined regardless of the differences in the aim
19
19
and study design. For instance, two studies directly investigated the effectiveness of
massage therapy with comparison to group receiving standard treatment (McClurg et
al., 2011 & La m̈a°s et al., 2010); one study indirectly examined the effect of massage
therapy in relieving constipation with the results reflected in the data concerning the
health-related quality of life (La m̈a°s et al., 2009). Another two studies, one aimed to
compare the effectiveness of laxative and massage in relieving constipation (Emly et
al.,1998), while the other used classical massage therapy as control to examine the
effect of another intervention (Kassolik et al., 2015). Various outcome measurement
stools were used to determine the severity of constipation, colon transit time,
perceived health status and the bowel status. From the TOE listed in below
Appendices, the effect size varied from study to study; some of the studies failed to
demonstrate a significant difference between intervention and control such as the
secondary outcome measure in the study of McClurg et al. (2011). However, overall
results were consistent with each other studies that abdominal massage had
demonstrated significantly positive effect in alleviation of constipation.
There were also variations of the content of massage therapy in the five studies.
One researcher suggested that the length of massage should be long enough to provide
effects (Emly et al., 1998). There was no standardized technique of performing
abdominal massage; the therapy was provided by caregivers (McClurg et al., 2011),
nurses (La m̈a°s et al., 2009 & 2010) or physiotherapist (Emily et al., 1998 &
Kassolik et al., 2015) in the studies selected.
2.3.2 Synthesis
Despite the results of the five studies prone to suggest abdominal massage as an
effective, alternative method in relieving constipation, there were diversities in the
20
20
study conclusion drawn. The reasons behind such differences could be multifold, and
will be further discussed in the following parts.
The five studies were conducted in 3 different countries: Sweden, Poland and
United Kingdom respectively. Cultural difference may be the contributing factors
affecting the study result. For instance, Kassolik et al. (2015) pointed out that
abdominal massage is an intimate action that might induce embarrassment to the
participants that might affect the study result. Therefore, cultural sensitivity and
consideration is an important issue to think about in systematic review of the
literature.
Concerning the demographic data, no significant difference was detected
between the intervention and control group at the beginning of the five studies, hence
suggesting a greater contrast in the result between intervention and control. However,
the characteristics of the five studies were quite difference. In one study, the subjects
recruited were profoundly disabled people (Kassolik et al., 2015), whereas in another
study, the participants were people with multiple sclerosis (McClurg et al., 2011). The
difference between subjects probably accounts for the distinction between the study
result and conclusion.
For the blinding issue, it was not possible to blind the subjects and researchers
due to the nature of some studies (McClurg et al., 2011; La m̈a°s et al., 2009 & 2010).
High level of blinding to the subjects, therapists and analyzers can ensure the
objectivity of the study and thus, bias can be minimized.
21
21
Moreover, the measurement tools used for the five studies were quite different.
Diary was used for measuring the degree of straining experience and number of bowel
movement in the study of Kassolik et al. (2015), which was simple for the participants
to understand and record. However, the compliance of completing diary was low in
the study of McClurg et al. (2011), and the data of the bowel pattern among
participants was insufficient to determine the effect of abdominal massage in
management of constipation. Therefore, it is important to encourage and reinforce the
completion of data if diary is used. On the other hand, it was quite common for the
number of bowel movement to be used as an outcome measure, which was used in
three out of the five studies (La m̈a°s et al., 2009; Emly et al., 1998; Kassolik et al.,
2015). The advantages of measuring the number of bowel movement per week are
multifold: it is easy to determine the effect of abdominal massage in terms of the
frequency of defecation, since constipation is defined as less than three defecations
per week (Xin et al., 2014). Unlike other bowel symptom like straining, it is an
objective data so that errors due to bias or personal perceptions can be avoided.
Therefore, the number of bowel movement should be considered as appropriate for
outcome measure in this proposed study.
2.3.3 Implication
To conclude, all the selected studies revealed that the abdominal massage is
effective in alleviating constipation based on the systematic review of five RCTs. The
evidences support the application of massage therapy in target setting. Therefore, an
evidence-based practice guideline of using abdominal massage to prevent constipation
is worthy for implementation in O&T units to improve patient outcome and the
quality of care.
22
22
CHAPTER 3
TRANSLATION AND APPLICATION
In Chapter Two, the integrated review of several high-quality studies
demonstrated that abdominal massage is effective to alleviate constipation. Therefore,
it is worthy to translate the corresponding evidence and develop an evidence-based
practice guideline of applying such therapy to maximize patient outcome and quality
of service. Before applying the intervention to the local setting, it is necessary to
assess the implementation potential in terms of transferability, feasibility and
cost-benefit ratio, which will be discussed in this chapter.
3.1 Transferability
In determining the implementation potential of a proposed innovation in a target
setting, transferability is one important issue that should be considered. The word
“transferability” refers to the extent to which the studies’ findings can be applied and
fit to different settings or organization, which is “a direct function of the similarity
between the two situations or their associated fittingness” (Finfgeld-Connett, 2010).
In this part, target setting, type of clients and philosophy of care will be further
discussed.
3.1.1 Target setting and population
Abdominal massage is proposed to be implemented in Department of Orthopedics
& Traumatology (O&T) in a public hospital which provides in-patient and out-patient
service to a large population in the cluster. The admission of patients to O&T wards
includes emergency type through Accident & Emergency unit as well as clinical type
23
23
for scheduled operation or therapy. There are four acute wards and three rehabilitation
wards in O&T unit, providing continuous and comprehensive care to the patients.
The target clients of the proposed innovation are both female and male patients
aged 18 or above, who are suffering from different kinds of orthopedic problems in
hip that required surgical intervention. Age of 18 or above is considered as one of the
entry criteria for the proposed care because individuals in this age group are adult and
would be able to give legal consent for the study. Although female outnumbered male
in population of constipation (Gary, 2014), both male and female patients are included
because constipation affects individuals at both genders. To avoid language barrier,
individuals who speak language other than Cantonese and English will be excluded.
In addition, the target clients should be communicable and do not have hearing or
cognitive impairment.
3.1.2 Transferability of findings
To assess whether abdominal massage can be applied to local setting, a
comparison of the demographic characteristics of target clients and the population of
reviewed studies is essential. Concerning the age, all participants in the five selected
studies were aged over 18 or above, with mean age ranging from 42.25 to 63.7
(McClurg et al., 2011; La m̈a°s et al., 2009 & 2010; Emly et al., 1998; and Kassolik
et al., 2015), which is similar to the target population that all are adults and majority
of them fall into the age group of 58-72. Moreover, there is no significant difference
in gender distribution between target population and the participants recruited in the
five studies; both were dominant by female.
24
24
Another consideration is the racial and cultural background of the identified
populations. Among the five reviewed studies, two of them were done in Sweden
(La m̈a°s et al., 2009 & 2010), another two were carried out in the United Kingdom
(Emly et al., 1998 & McClurg et al., 2011) and one conducted in Poland (Kassolik et
al., 2015). This suggests that constipation could be a worldwide health problem that
affects individuals in difficult countries with different ethnicity. Although the
population in target setting consists of Chinese in majority whereas those of reviewed
studies conducted in western countries, there is no evidence suggesting abdominal
massage exerts different effect in management of constipation among different ethnic
groups. Therefore, ethnicity should not be considered as a determinant affecting the
transferability of the findings.
3.1.3 Philosophy of care
The aim of proposed care is to help patients who undergone hip surgery to reduce
the likelihood of developing constipation as well as the associated complications so as
to enhance the quality of life, and shorten the patients’ length of stay in hospital.
Being a public hospital in Hong Kong, the target hospital and the O&T
Department shared similar mission with Hospital Authority (HA) that emphasizes
“client-oriented care” and stresses the importance of quality service. “Vision”,
“Mission” and “Values” are three core values of HA (Vision, Mission and Values,
2016). In recent years, HA emphasize the staff training and development; continuous
quality improvement program, education and research were promoted to ensure safety
and quality of service provided. New innovations are also encouraged to improve the
existing practice and empower non-medical staff such as nurses to enhance the
patients’ wellbeing and optimize their capability to reintegrate to community.
25
25
The proposed massage therapy is expected to reduce constipation among target
clients and improve their quality of life; it meets the philosophy of O&T Department
and is in line with the core values of HA. Therefore, it is more likely to gain full
support from department and the hospital.
3.1.4 Number of clients to be benefited
According to my clinical observation, there were around 1600 patients admitted
to the four acute orthopedic wards of the target hospital yearly. Among these patients,
approximately 40%, i.e. 640 of them required hip surgery and the proportion is quite
constant every year. Nevertheless, not all of them are eligible for my study; some
might be excluded due to hearing and cognitive impairment, unfit physical condition,
language barrier, etc. A proportion of them maybe lost due to deaths, transfer to
another hospital in the same cluster for rehabilitation or early discharge. Hence, it is
estimated that only 60% of the post-operative cases of hip surgery, i.e. 384 patients,
will be available to participate in the proposed massage therapy.
3.1.5 Implementation and evaluation
The proposed project will be divided into three major phases: (1) preparation; (2)
implementation, and (3) evaluation phases, which will take a period of 12 months in
total.
In the preparation phase, two months will be required to write the proposal.
Another two months will be spent on communicating with other involved parties and
proposing the project to Chief of Service (COS) and Department Operational
Manager (DOM). After getting approval, two months will be used to prepare
education materials, questionnaire and provide internal training to nurses. In
26
26
implementation phase, a one-month pilot study will be carried out in the four acute
wards (two male and two female wards) to collect data for modification of the study.
After that, the proposed care will be implemented and lasted for three months. In the
last phase, two months will be allowed for data collection and analysis to evaluate
whether the objectives are achieved. A timeline of the program is available in
Appendix 14.
3.2 Feasibility
Feasibility of an innovation depends on various practical concerns including the
organizational climate, administrator support, availability of staff, skills and resources,
autonomy of nurse to control over the innovation, friction within organization, and the
potential for clinical evaluation.
3.2.1 Organizational climate and administrator support
In the selected setting, the climate of implementing a new program is positive. In
every year, the hospital would invite all departments to participate in the “Kaizen
project”, i.e. to implement new innovation to improve the current practice and
enhance patient outcome. The project is greatly supported by the administration level
of the selected department by providing nursing empowerment in initiating changes
and the staff also actively participates.
Furthermore, the administrator of the selected setting highly promotes EBP in
ward. EBP is highly valued to enhance the nursing professional status and quality of
service. All staff is encouraged to participate in nursing forum and research study in
order to provide the best possible care. As the proposed care was developed based on
empirical evidences, it is likely to gain support from the administrator.
27
27
3.2.2 Availability of staff, skills and resources
Continuous staff training and development are greatly supported by the
administrators. Majority of the registered nurses within the department are holder of
Nursing Degree and more than half had completed their Master degree in Nursing.
Besides, the working experience of registered nurses of the seven involved wards is
around 6-10 years in average with nearly half had completed their post registration
certificate course, implying that the nurses should be knowledgeable and experienced
enough for the new implementation.
Under support from the administrators, a organizing committee will be established
which consists of a consultant, nurse specialist (NS), one ward manager (WM) and
one registered nurse (RN) from each involved O&T ward. Assigned RN in each ward
will be counted as extra manpower that they will be exempted from ward duties, thus
minimizing interruption to ward operation.
The group is responsible for the coordination of the whole implementation
including provision of training to other staff, allocation of resources, and
communication with different stakeholders. Train-the-trainer session will be provided
to three RNs in each of the wards to ensure that they are capable to assess the
patient’s risk of developing constipation, evaluating the severity of constipation,
performing abdominal massage, monitoring the patient’s bowel pattern, etc.
Concerning the resource, hardware like venue for meeting and training sessions,
computers and projectors are necessary, and is available in the activity room of one
O&T rehabilitation ward. Materials for training and evaluation such as notes and
questionnaires are also needed.
28
28
3.2.3 Autonomy to initiate and terminate the intervention
The proposed intervention, abdominal massage, is an evidence-based nursing
intervention that could be initiated without physician’s order. Being important
characteristics of a profession, nurses in the selected department have the autonomy
(Keogh, 1997) to make decisions on the duration and type of massage applied; they
are empowered to monitor the effect of the new practice and have the power to
terminate the therapy based on the participant’s tolerance.
3.2.4 Friction within organization
Introduction of the proposed care to medical staff is essential because need of
additional medical treatment for constipation is govern by the effectiveness of the
massage therapy. A detailed proposal of the intervention will be sent to all doctors
and the hardcopy will be kept in ward for doctor’s quick reference. Little opposition
force is anticipated since the proposed intervention is implemented within O&T unit
without involvement of other departments.
3.2.5 Potential for clinical evaluation
A process evaluation is a vital part of a program to ensure the proposed care is
carried out smoothly. A formative evaluation will be carried out in the middle of the
implementation to obtain useful data for further improvement of the new intervention.
At the end of the implementation, a summative evaluation will be performed to
determine the effectiveness of the innovation. Primary and secondary outcomes are
the keys to measure the overall achievement of the new practice. The primary
outcome is directly measured in terms of the number of defecation per week. The
secondary outcome would be patient’s quality of life using health survey as
assessment tool.
29
29
3.3 Cost-Benefit Ratio
To determine whether the proposed innovation is worthy to implement, it is
necessary to the estimate the cost and benefits to several parties such as the clients,
staff and the organization. In addition, the material and non-material cost, the costs
and benefits of not instituting an innovation should be considered as well (Polit &
Beck, 2008).
3.3.1 Potential risk
Abdominal massage is considered as a relatively safe, non-invasive practice with
little or no risk reported (La m̈a° s, 2011), and can be applied to individual of all ages
(Smith & Moss, 2008). However, patients with known or suspected abdominal
obstruction, with abdominal mass, and those who receive radiotherapy to their
abdomen within six weeks are contraindicated to the therapy (Preece, 2002).
Therefore, medical history must be reviewed by nurse in prior to minimize the risk.
Patients would also be educated to observe and report any discomfort during the
therapy.
On the other hand, not all staff would welcome and have interest in the new
practice since massage therapy is relatively time-consuming (Ernst, 1990) that some
may have a low morale to participate. Also the program may increase their working
stress and hence affecting their working performance.
3.3.2 Potential benefit
As mentioned in previous chapter, abdominal massage can relieve constipation
and effectively reduce the undesirable physiological and psychological consequences
owing to the symptoms and stress to individuals. The total colonic transit time was
30
30
significantly reduced in patients with higher level of spinal cord injury, where they
could not control the abdominal muscles to increase intra-abdominal pressure (Ayas
et al., 2006). Although limited studies show that abdominal massage can entirely
replace the traditional use of medication for constipation (Faleiros & de Paula, 2013),
such a practice could offer alternate therapy for patients who are reluctant to drug use.
Therefore, patients are empowered and their autonomy of choice of treatment is
respected.
Apart from patients, staff can also benefit from the intervention. Due to the
nature of massage, physical touch is involved which is a powerful, non-verbal mean
of communication (Smith & Moss, 2008). Trust and rapport will be built between
nurses and patients.
Unlike other duties of nurse such as doing documentation and implementing care
plan, massage is “visible”, “concrete” and “quantifiable”; patients and relatives may
appreciate for the effort paid by nurses and hence, more likely for the nurse to gain
job satisfaction and working incentives. Furthermore, the proposed massage therapy
provides opportunities for nurses to carry out an evidence-based practice; nurses
could enjoy a high level of autonomy. Communication and organization skills of
involved nurses could also be improved.
On the economic perspective, successful implementation of this project is
expected to reduce constipation and its associated complications. As a result, the
length of hospital stay and health care expenditure will be reduced.
31
31
3.3.3 Cost Estimation
Cost of running a program can be divided into material and non-material costs.
For the material cost, it includes set-up cost and operational cost. Personnel
expenditure makes up the set-up cost. Totally one nurse specialist and seven RNs
from the organizing committee will involve in the meetings and preparation work,
with approximate 8 hours expected to be spent. Moreover, total twenty-one RNs from
the seven wards will form the working team where they will attend one briefing
session and one train-the-trainer workshop in the preparation phase, and each will last
for 1.5 hours. The expenditure on personnel salary is shown in Appendix 15.
For the operational cost, a large proportion accounts for the cost of massage
therapy. Nurses will spend around 30 minutes daily for the proposed intervention: 5
minutes to prepare a comfortable environment before, 20 minutes to perform the
therapy and another 5 minutes to document the procedure. The team will spend 4
hours per week for data collection and analysis.
As mentioned before, approximately 384 patients in the target setting are eligible
for the program every year; whereas the average length of hospitalization due to
constipation was 5.6 days (Thomas, 2014). As the estimated operational cost of
serving a patient in general ward of public hospital is HKD $4680 per day (Fees and
Charges, 2015), a substantial expenditure can be saved by the proposed program. A
detailed calculation of the cost to be saved per year is shown in Appendix 16.
For non-material cost, sufficient time should be allowed for frontline nurses to
assimilate the new information and intervention. In addition, adequate briefing and
training are required to ensure the staff being competent for carrying out the program,
32
32
as hasty implementation could impose stress to staff that probably reduce their morale
and increase staff turnover rate which in turns harm to patients.
It is also important to note that some items are excluded as ‘hidden’ costs in the
cost calculation. For examples, the venue for meetings, paper materials (notes for staff
training and copy of guidelines keep in ward), photocopiers, computer accessories and
software are available in the unit so no extra cost needed. Besides, as the nurse
specialist in the team was used to be a physiotherapist, she could teach other nursing
staff about the massage technique so that cost could be saved from employing a
therapist. Furthermore, the costs of involvement of consultant and ward manager are
exempted because their participations are mainly as an advisor such that it is difficult
to quantify their working time.
On the other hand, the implementation of abdominal massage is expected to lead
to a reduction of laxative use. However, information about the exact reduction of
laxative use was limited and cannot be determined. Therefore, underestimation in
cost-saving regarding the implementation of program is anticipated.
In short, the cost to be saved per year from the new implementation is
$10,063,876 (See Appendix 16), which is much greater than the total cost of running
the program for one year, i.e. $459265.8 (See Appendix 15).
33
33
CHAPTER 4
EVIDENCE-BASED PRACTICE GUIDELINE
In view of the high susceptibility of target clients to constipation, the problem
needs our immediate attention and action. The use of abdominal massage in reducing
constipation has been reported as effective in various studies, yet its application to
patients after having hip surgery is rare in Hong Kong. As discussed in previous
chapters, the proposed intervention has a high potential for implementation. An
evidence-based practice guideline for prevention of constipation will be presented as
below with recommendations made upon the evidences from the reviewed articles.
Recommendations were graded regarding to the grading system developed by Scottish
Intercollegiate Guidelines Network (2014). After reviewing the five selected studies,
five recommendations are generated.
Title:
Evidence-based guideline of using abdominal massage to prevent constipation for
patients after having hip surgery
Aim
To establish a structured and comprehensive reference for nurses in O&T department
to implement evidence-based abdominal massage to prevent post-operative
constipation.
Objectives
1. To provide an instruction for nurses to apply the massage therapy;
34
34
2. To reduce the incidence and severity of constipation in target patients by applying
abdominal massage;
3. To provide optimal management of constipation based on the best available
evidence;
4. To encourage application of EBP within the department; and
5. To ensure that target patients receive safe, consistent and standardized care.
Intended User
Physicians and nurses are the major users of the guideline.
Target population
Evidence-based massage therapy would be provided to both male and female patients
in O&T unit who have undergone hip surgery.
The Inclusive criteria are:
– Aged eighteen or above;
– Post-operative cases of hip surgery; and
– No hearing and cognitive impairment
The exclusion criteria are:
– Used language other than English or Chinese;
– Known or suspected to have abdominal obstruction;
– Presence of abdominal mass; and
– Received radiotherapy within six weeks
Recommendation
To grade the levels of evidence and recommendations, the Scottish
35
35
Intercollegiate Guidelines Network (2014) was used as the tool. The hierarchy of
evidence is ranked from 1 to 4 that the highest level rated as 1++ and 4 as the lowest
level. Symbols of “++” “+” and “-” indicate the overall quality of the articles with
degree of bias from lowest to highest correspondingly. On the other hand, each
recommendation was presented with either one of four grading “A”, “B,” “C” and “D”
that grade A reflected the highest level of credibility and reliability for
recommendation and “D” reflected the lowest value for recommendation that should
be treated deliberately (See Appendices 1 & 7).
Recommendation 1.0
Environment for abdominal massage to take place should be comfortable and
relaxing. [Grade of recommendation: A]
A supportive, comfortable environment enables participants to relax, which could
maximize the effect of abdominal massage in stimulating peristalsis of intestine.
(La m̈a°s et al., 2009, 1+ ; Kassolik et al., 2015, 1+).
Recommendation 2.0
A position of lying flat is maintained throughout the massage therapy.
[Grade of recommendation: B]
A lying position enables participants to relax (La m̈a°s et al., 2009, 1+) and facilitate
the application of massage (Emily et al., 1998, 1-).
Recommendation 3.0
36
36
Duration of the massage therapy should last for 10-20 minutes.
[Grade of recommendation: A]
The five reviewed studies suggested applying massage with duration ranging from 10
to 20 minutes, and all showed positive effect in relief of constipation (McClurg et al.,
2011, 1+; La m̈a°s et al., 2009, 1+; La m̈a°s et al., 2010, 1- ; Emly et al., 1998, 1- ;
Kassolik et al., 2015, 1+).
Recommendation 4.0
Length of intervention should be eight weeks or above. [Grade of recommendation: A]
One of the reviewed studies suggested that three weeks of implementation was too
short to demonstrate significant effect of abdominal massage in management of
constipation (Kassolik et al., 2015, 1+). Besides, the mid-evaluation of other three
studies did not show great difference between intervention and control groups, where
significant difference were noted at the end of the studies, i.e. Week 8 (McClurg et al.,
2011, 1+; La m̈a°s et al., 2009, 1+; La m̈a°s et al., 2010, 1-).
Recommendation 5.0
Massage of circular movement in a clockwise direction should be adopted.
[Grade of recommendation: A]
Movement in a clockwise direction presumed the course of colon, which could induce
stimulation to the gut and hence facilitating peristalsis (McClurg et al., 2011, 1+;
La m̈a°s et al., 2009, 1+; Emly et al., 1998, 1-).
37
37
CHAPTER 5
IMPLEMENTATION PLAN
As discussed in Chapter Three, it is worthy to apply abdominal massage to
prevent constipation in the target setting with consideration of its cost and benefit.
However, successful implementation of a new practice depends greatly on the
administrators’ awareness of the significance of evidences, support from the
department, staff’s confidence about delivering the intervention and their adherence to
it (de Velde et al., 2016). Therefore, it is essential to establish an implementation plan
which includes a communication plan, a pilot test and an evaluation plan.
5.1 Communication Plan
Communication refers to a process of information transfer during which own
ideas and understandings can be exchanged interpersonally. In implementation
science, communication is the key to promote and turn the evidence-based research
findings into the clinical setting (Manojlovich, 2015). The contents of the proposed
care will be presented to the potential stakeholders through systemic communication
panel to get their support and approval.
5.1.1 Identification of stakeholders
Stakeholders are groups or individual who can exert influence over or are
influenced by an issue (Schiller et al., 2013). To initiate changes in clinical setting, it
is important to address the interest of potential stakeholders with regard to the
objectives of the innovation. For the proposed care, the potential stakeholders can be
classified into four different groups: (1) the administrator of the department; (2) the
38
38
nurse; (3) the doctors, and (4) the target population.
Administrators include the Chief of Service (COS) and the Departmental
Operation Manager (DOM) of the O&T Department in the target hospital, who are at
the top level responsible for the departmental operation and allocation of resources.
They have the authority to make the final decision for adoption and implementation of
new policies or intervention.
For the nursing discipline, a nurse specialist (NS), a ward manager (WM) and
seven registered nurses (RN) from O&T Department will form an organizing
committee responsible for planning, implementation and evaluation of the project.
The NS acts as the project coordinator whereas the WM act as the advisor for the
project. Another twenty-one RNs will form a working team responsible for providing
massage therapy to the target patients.
For the medical discipline, doctors act as the collaborative partners with nurses
that they are interdependent; new practice in either discipline may affect the other one
so that good communication between doctors and nurses is necessary. A consultant
will also be invited to be the advisor for the proposed care.
It is important to note that patients and their relatives are also stakeholders
because the implementation of proposed care requires their consent and support. The
effectiveness of the proposed care also directly affects the health and life quality of
the target patients.
39
39
5.1.2 Communication process
Effective communication can maximize the congruence between the expectations
of different stakeholders and increase the likelihood for a successful implementation
of an innovation. To ensure good communication between different parties, a concrete
communication plan is essential. The estimated duration of the communication plan
lasts about two months (See the flowchart in Appendix 18).
i. Communication with administrator
Upon addressing the clinical issue and affirming the needs of implementation, a
proposal should be made and presented to the departmental administrators, i.e. COS
and DOM.
In the presentation, the severity of constipation in local setting, program
objectives, implementation timeline, budget and evaluation plan will be introduced.
The content should be made concise and precise; emphasis on the significant research
findings, cost-effectiveness of the proposed care and its potential benefit to patients
should be made to convince the administrators that new change is necessary.
ii. Communication with doctor
The proposed innovation will be introduced to all O&T doctors via e-mail. The
evidence-based benefits of abdominal massage will be emphasized and presented
during the doctors’ weekly conference in order to get their support and cooperation.
iii. Communication with nurse
The communication channels among nursing staff include e-mail, handover in
ward and the monthly nursing meeting. Increased autonomy for nurse, improved
40
40
nurse’s professional image, better rapport between nurse and patient as well as
enhanced patient outcome will be highly promoted. As the staff involved in the
organizing committee and working team may feel stressed for the new innovation,
training and support will be emphasized in the nursing meeting.
iv. Communication with patient and relative
Patients are the direct recipients of care in the new implementation that their
health and life quality will be affected by the proposed innovation. Pamphlets would
be designed and delivered to the eligible individuals in order to enhance their
understanding and acceptance.
5.1.3 Communication strategies
i. Initiating the change
The proposed innovation aims to prevent constipation in target setting. To initiate
change, the proposer should prepare and present the proposal to the administrative
level in order to obtain their support and approval. Upon getting the approval, the
proposer has to coordinate with the other staff to form the organizing committee and
working team.
To maximize the information coverage, the committee will adopt various
communication channels as discussed above to ensure the proposed care is
well-disseminated to stakeholders from all levels.
41
41
ii. Guiding the change
The main role of the committee is to coordinate all the implementation activities
and to encourage the advance of the changing process. An implementation timeline
will be set up to guide the changing process (presented in Appendix 14). The proposer
and the NS will act as the collaborators to deal with problems and barriers arise
during the changing process. Together with the seven RNs, they have to monitor the
progress and keep the implementation on schedule. On the other hand, the two
advisors will provide comments on the EBP guidelines and clarify any
misconceptions to ensure that the whole implementation is in the right direction.
iii. Sustaining the change
To make the new innovation a success, the committee should take an active role
in assessing the nurse’s compliance. The skills and knowledge on abdominal massage
would be audited regularly to ensure the nurses are competent in providing high
quality care. Moreover, the patient outcomes would be monitored to evaluate the
effectiveness of the program. Feedbacks about the innovation are also welcome and
all participants would be invited to express their opinion toward the new practice
during the meeting. Recommendations from all parties will be considered seriously
for the guideline refinement.
5.2 Pilot Study Plan
After communication with the stakeholders and staff training are completed, a
small-scale testing, known as pilot study, will be conducted. Pilot study is actually
preliminary or trial run of a full-scale research study performed to evaluate the
feasibility and transferability of intervention (Cope, 2015). Through this process,
potential barriers and problems could be identified so that the innovation could be
42
42
revised and modified before conducting the actual large-scale implementation.
5.2.1 Setting and duration
The pilot study will be conducted in the O&T Department of the target hospital,
involving the staff and patients from four acute wards and three rehabilitation wards.
Integrated activity room will be the location for staff training, meeting and massage
therapy, which is the same place for the full-scale implementation. Duration of the
pilot study will be one month.
5.2.2 Subject recruitment and sample size
Convenience sampling method is adopted to recruit a pool of adult patients who
have undergone orthopedic hip surgery. To evaluate the project feasibility, the
inclusion and exclusion criteria in the pilot testing should be identical to that of the
full-scale implementation to minimize inaccuracy due to subject difference. As
mentioned in Chapter Three, the admission number for the target population is quite
constant every year. Based on my clinical observation, approximate 30 patients can be
recruited for the pilot test.
5.2.3 Details of the pilot study
Facilitation is an important process in launching a pilot test to liaise different
individuals or parties to cooperate and achieve a goal in common (Kitson & Harvey,
2016). Being the facilitator of the new innovation, all committee members are
responsible for preparing the EBP guideline and promote the advance of changing
process. The one-month testing will be started upon the completion of the staff
training.
43
43
For each newly admitted case, the committee will screen for the eligibility based
on the selection criteria using a referral form (See Appendix19). Informed consent
will be obtained from the target patients with all potential benefits and risks being
stated. The massage therapy will be started on post-operative Day 2 to avoid
intolerance due to immediate physiological response caused by anesthesia and
analgesics. Nurses from the working team will spend 10-20 minutes daily for the
massage therapy until patient discharge.
5.2.4 Data collection and instrument
Before applying abdominal massage, initial nursing assessment will be performed
to acquire demographic information for baseline data using a designated form (See
Appendix 20). Besides, a SF-12 Health Survey (See Appendix 21a & b) will be used
to assess for any change in patient’s health-related quality of life (HRQoL) before
and after the program. At the end of the program, a questionnaire will be delivered to
the participants to evaluate the effectiveness of the massage therapy program (See
Appendices 22a & b). All the data obtained from the pilot test will be included in the
data analysis and is significant for the evaluation of the whole innovation.
5.2.5 Evaluation of pilot study
Based on the primary aim of conducting a pilot test, the acceptability, feasibility
and compliance of staff for the proposed care will be reviewed; comments and
recommendations about the implementation are also welcome for further refinement
of the clinical guideline.
44
44
i. Assessing acceptability
The acceptability of staff to the proposed care could be determined by a staff
satisfaction questionnaire (See Appendix 23), which will be distributed to nurses at
the end of the pilot study. The data generated can directly indicate if they accept the
proposed care and guideline.
ii. Assessing feasibility
Feasibility of a project depends largely on the availability of various resources
including personnel, time and funding. By running a pilot test, the exact amount of
resources required can be measured. Such information is helpful in determination of
resource allocation and budget planning, predicting the possibility for the full-scale
implementation.
iii. Assessing compliance
The committee members will carry out auditing every month until the patient
discharge using the form attached in Appendix 24 to check for nurse’s compliance to
the EBP guideline. On the other hand, the nurse who performs abdominal massage
should document immediately after each massage session using a designated record
form (See Appendix 25).
iv. Interventions after Pilot Testing
At the end of the pilot study, each nurse will complete a questionnaire to evaluate
the effectiveness of the proposed innovation (See Appendix 26). The organizing
committee will hold a meeting and invite all potential users to share their experiences
on the innovation. Comments and suggestions toward this intervention are encouraged
to clarify possible ambiguities during the pilot study. All the recommendations
45
45
collected will be used to rectify any underrating issues and refine the guideline for the
large scale implementation.
5.3 Evaluation Plan
Evaluation is crucial to determine the effectiveness and the achievement of
outcomes of a proposed innovation. The terms “process evaluation” is regarded as the
procedure of reviewing a program in terms of the benefits and unintended
consequences identified (Jaegers et al., 2014); these provide a clear direction for the
administrator to determine the sustainability of the innovation and the need of further
refinement in guideline.
5.3.1 Identification of outcomes
i. Patient outcome
Patient outcomes can be further classified into primary and secondary. For the
proposed care, the primary outcome is to increase the number of defecations per week,
since the frequency of bowel movement is one of the significant criteria for diagnosis
of constipation (Xin et al., 2014).
Change in QoL, on the other hand, is the secondary outcome to be assessed.
According to five studies reviewed before, constipation is greatly associated with a
decreased HRQoL since it will cause physical, psychological and mental burden to
the individuals.
46
46
ii. Health care provider outcome
Staff compliance is one indicator to reflect the effectiveness of an innovation,
which implies their acceptance to new changes. To test for their compliance, auditing
will be performed monthly by the organizing committee till patient discharge.
Besides, the skills, knowledge and competence of nurse are also important
parameters to indicate the success of the intervention. With sufficient staff training,
nurses will be empowered and competent to perform abdominal massage. As the
proposed care is nurse-initiated evidence-based practice, nurses can therefore enjoy
high level of autonomy; enhanced patient outcome is expected and hence, increase job
satisfaction of nurses.
iii. System outcome
With the application of abdominal massage, the postoperative complications
related to constipation are expected to be minimized. Thus, the length of
hospitalization will be reduced such that resources and expenditure spent on
management of constipation will be saved.
5.3.2 Nature and number of Clients to be involved
The eligibility criteria of recruiting clients should be consistent with that for
recruitment in pilot study to ensure homogeneity of patient groups. The target group
consists of both female and male patients aged 18 or above, who required surgical
intervention to their hip joint. For those who speak language other than Cantonese and
English, having hearing or cognitive impairment will be excluded.
47
47
To ensure the subject recruitment being large enough to generate similar effect
size as that of the studies reviewed (See TOE in Appendices 4-8), an appropriate
sample size calculation is necessary. In the proposed program, the sample size
depends on the primary outcome measures, i.e. the frequency of defecation per week.
An online software called G-power is adopted whereas a one sample t-test is used
(G*Power, 2012). The effect size of the reviewed studies ranged from 1.104 to 1.3
(La m̈a° s et al., 2009; Kassolik et al., 2015), whereas 1.104 will be considered and
used for conservative estimation. The level of significance and the power will be set
at 0.05 and 80% respectively. By calculation, the recommended sample size is 98.
Since the average attrition rate for the five reviewed studies (McClurg et al., 2011;
Emily et al., 1998; La m̈a°s et al., 2009 & 2010 ; Kassolik et al., 2015) is 7.47%, 105
patients should be recruited with convenience sampling over a period of three months.
5.3.3 Time and frequency to take measurements
The time and frequency for each outcome measure may vary due to different
effects exerted by different parameters in the study. Demographic information will be
collected at the beginning to obtain baseline data.
Before the start and in between of the massage therapy, the number of bowel
movement per week will be recorded. Concerning the patient’s QoL, a SF-12 Health
Survey will be delivered to patients before and after the innovation to evaluate if there
is improvement of QoL.
For the health care provider outcome, the staff compliance will be determined
via audit on a monthly basis and upon the patient discharge. On the other hand, the
skills, knowledge and competence of nurse will be evaluated immediately after the
48
48
staff briefing and training session, pilot study and at the end of the whole study.
With regard to the system outcome, the change in length of hospital stay as well
as the resources and expenditure spent on management of constipation can be
established by reviewing the annual expenditure at the end of the implementation.
5.3.4 Data analysis
Data collected in the pilot study and the full-scale implementation will be
analyzed by Statistical Package for Social Science (SPSS). The results of all outcome
measures are considered as statistically significant if the p value is less than 0.05.
Descriptive statistics of demographic information are used to reflect the
characteristics of the participants for comparison. Such data can be obtained from the
initial nursing assessment before massage therapy and will be assessed by using
Chi-square tests.
As the primary outcome measure, the change in number of bowel movement
after the intervention will be examined by reviewing the record form (See Appendix
25); for patient’s QoL, data analysis will be performed based on the information
obtained before and after the intervention using one-sample t-test.
In view of the health care provider outcome, the nurses’ perception on the new
innovation, enhancement in the skills, knowledge and confidence after the training
sessions, satisfaction of the guideline would be analyzed based on the data obtained
from the questionnaire.
49
49
For the system outcome, the change in length of hospitalization and expenditure
will be determined by independent t- test with 5% level of significance.
5.3.5 Criteria for considering a practice as effective
To regard an innovation as effective, the data analysis for outcome evaluation
must be of 0.05 level of evidence to consider as statistically significant. Based on the
literature review done in Chapter Two, the innovation will be regarded as effective if
the primary outcome, i.e. the patient’s number of bowel movement per week is
increased by one time or more after the intervention. Moreover, the intervention can
improve the quality of life in patients; it is also expected to enhance staff development
by providing training; an improvement more than 50% in scoring of the questionnaire
regarding patient’s HRQoL, nurse’s satisfaction toward applying EBP guideline will
indicate the success of the intervention.
5.4 Conclusion
Constipation is a prevalent health problem with various health consequences
associated. Abdominal massage, being proven by high quality research studies, can
provide a safe and non-invasive way to prevent constipation among the susceptible
individuals in the target setting. With the implementation of massage therapy, patients’
outcomes and quality of life, standard of practice, job satisfaction of nurse can be
improved. For health system as a whole, the resource can be saved owing to a
decrease in length of hospital stay.
50
50
Appendix
Appendix 1: Key to evidence statements and grades of recommendations
Scottish Intercollegiate Guidelines Network (2014)
Level of evidence Evidence statements
1++ High quality meta-analyses, systematic
reviews of RCTs, or RCTs with a very
low risk of bias
1+ Well conducted meta-analyses,
systematic reviews, or RCTs with a low
risk of bias
1- Meta-analyses, systematic reviews, or
RCTs with a high risk of bias
2++ High quality systematic reviews of case
control or cohort studies;
High quality case control or cohort
studies with a very low risk of
confounding or bias and a high
probability that the relationship is causal
2+ Well-conducted case control or cohort
studies with a low risk of confounding or
bias and a moderate probability that the
relationship is causal
2- Case control or cohort studies with a
high risk of confounding or bias and a
significant risk that the relationship is
not causal
3 Non-analytic studies, e.g. case reports,
case series
4 Expert opinion
51
51
Appendix 2: Table of search strategies
Search
ID
Keyword Results
CINAHL
Plus
Medline British
nursing
index
eKG
#1 Constipation 1107 2922 638 520
#2 Bowel symptom 206 116 301 262
#3 Abdominal
massage
18 32 23 42
#4 Postoperative 14479 48088 2077 6680
#5 Hip Surgery 1148 1037 745 512
#6 #1 or #2 1256 3007 888 581
#7 #4 or #5 16390 55688 2982 7132
#8 #3 and #6 7 10 16 8
#9 #6 and #7 105 592 58 27
Limited to publication from
1995 to 2015
7 8 14 7
Eligible articles according
to inclusion and exclusion
criteria
2 2 1 5
Duplication / 2 1 2
Reference tracing 0 0 0 0
Subtotal 2 0 0 3
Total number of studies
identified
2 + 0 + 0 + 3 = 5
52
52
Appendix 3: PRISMA 2009 Flow Diagram
53
53
Appendix 4: Table of Evidence A
(a) Scottish Intercollegiate Guidelines Network (2014) (e) Scale to evaluate the quality of life of patients with MS
(b) For making a diagnosis of constipation (f) 30-item questionnaire to assess the bladder-related quality of life in neurological patients
(c) 8-item questionnaire to describe the severity of constipation (g) Diary recording bowel pattern for 7 consecutive days
(d)10-item questionnaire to measure the degree of bowel dysfunction
Bibliographic citation/
Study type/ Level of
evidence
Sample
characteristics
Intervention (I) Control (C) Length of study Outcome measures
Effect size (ES)
(Intervention-control)
McClurg, D., Hagen, S., Hawkins, S. & Lowe-Strong, A. (2011). Abdominal massage for the alleviation of constipation symptoms in people with multiple sclerosis:
a randomized controlled feasibility study. Multiple Sclerosis Journal, 17(2), 223-233.
- McClurg et al.(2011)
- Randomized control
trial
- 1+ ---(a)
- Mean age: 55yrs
(SD=13)
- 18 (60%) female
- A confirmed
diagnosis of multiple
sclerosis (MS)
- Fulfilled the Rome
II criteria for
constipation ---(b)
- Provision of advice on
bowel management; and
- Education to patients or
caregivers on how to
deliver abdominal
massage with
recommendations to
perform it daily for a 4-
week intervention period
(n = 15)
Provision of
bowel
management
advice only
(n = 14)
-8 weeks in total
- Week 0
(Baseline/ pre
intervention)
- Week 4 (Post
intervention)
- Week 8
(Follow-up)
Primary:
(1) Constipation Scoring
System(CSS)---(c)
Secondary:
(2) Neurogenic Bowel
Dysfunction Score
(NBDS);---(d)
(3) Multiple Sclerosis Impact
Scale (MSIS);---(e)
(4) The Qualiveen
Questionnaire---(f)
(5) 7-day bowel diary---(g)
Week 0 to Week 8:
(1) -3.6
(2) -5.01
(3) & (4) No data
indicated (just
mentioned no
significant difference)
(5) N/A (as diary
poorly completed)
54
54
Appendix 5: Table of Evidence B
(a) Scottish Intercollegiate Guidelines Network (2014)
(b) For making a diagnosis of constipation
(c) System commonly used in cost effectiveness analysis for calculation of health gains in quality-adjusted life years (QALYs)
(d) Consists of five statements about mobility, self-care, usual activities, pain/discomfort and anxiety/depression using a 3-point Likert scale ranging from ‘no problem’ to ‘great problem’.
(e) Scale ranging from 0 (the worst imaginable health state) to 100( the best imaginable health state)
Bibliographic citation/
Study type/ Level of
evidence
Sample characteristics Intervention (I) Control (C) Length of study Outcome measures
Effect size (ES)
(Intervention-control/
comparison of p value)
La m̈a°s, K., Lindholm, L., Engstro m̈, B. & Jacobsson, C. (2010). Abdominal massage for people with constipation: a cost utility analysis. Journal of Advanced
Nursing, 66 (8), 1719-1728.
- La m̈a°s et al. (2010)
- Randomized control
trial
- 1- ---(a)
- Mean age: 63.7
- 26 (52%) female
- Fulfilled the Rome II
criteria for constipation
---(b)
- Abdominal
massage for 15
minutes/day for 5
days/week for
8 weeks; and
- Laxative intake was
changed or ended
gradually on basis of
clinical judgment
(n = 25)
Continued
with the
original
therapy used
(n = 25)
-8 weeks in total
- Week 0
(Baseline/ pre
intervention)
- Week 1-8
(intervention)
-Week 4 & 8
(Questionnaire
administered)
EQ-5D classification
system---(c)
(1) Health state
description (profile)
---(d)
(2) Visual Analogue
Scale (VAS)
Week 0 to Week 8:
(1) 0.004 [p=0.088]
[Not statistical
significant as p >0.05]
(2) 0.950 [p=0.011]
[ES is large because
sufficient benefits if
score ≥ 0.076]
55
55
Appendix 6: Table of Evidence C
(a) Scottish Intercollegiate Guidelines Network (2014)
(b) For making a diagnosis of constipation
(c) A self-administered questionnaire divided into 5 subscale with Likert scale ranging from 1 (no discomfort) to 7 (very severe discomfort)
(d) A seven point Lickert scale where 1 represents ‘‘separate hard lumps like nuts’’ and 7 ‘‘watery, no solid pieces’’
Bibliographic citation/
Study type/ Level of
evidence
Sample characteristics Intervention (I) Control (C) Length of study Outcome measures
Effect size (ES)
(Intervention-control/
comparison of p value)
La¨ma˚s, K., Lindholm, L., Stenlund, H., Engstro¨ma, B. & Jacobsson, C. (2009). Effects of abdominal massage in management of constipation - A randomized
controlled trial. International Journal of Nursing Studies, 46, 759-767.
- La m̈a°s et al. (2009)
- Randomized control
trial
- 1+ ---(a)
- Over 18 years of age
- Fulfilled the Rome II
criteria for constipation
---(b)
- Abdominal
massage for 15
minutes/day for 5
days/week for
8 weeks; and
- Instruction to
take less laxative
when experienced
improved
gastrointestinal
function
(n = 25)
Continued with
the original
therapy used
(n = 25)
-8 weeks in total
- Week 0
(Baseline/ pre
intervention)
- Week 1-8
(intervention)
-Week 4 & 8
(Questionnaire
administered)
Primary:
(1) Gastrointestinal
Symptom Rating
Scale (GSRS)---(c)
(2) Constipation
(3) Abdominal pain
(4) Indigestion
(5) Diarrhoea
(6) Number of bowel
movement
Secondary:
(7) Bristol scale---(d)
(1) -0.262 [p=0.003]
(2) -0.518 [p=0.014]
(3) -0.164 [p=0.074]
(4) -0.124 [p=0.150]
(5) 0.036 [p=0.099]
(6) 1.104 [p=0.016]
(7) -0.670 [p=0.38]
[ES was large using
outcome measure (6);
and ES was medium for
the other outcome
measures]
56
56
Appendix 7: Table of Evidence D
(a) Scottish Intercollegiate Guidelines Network (2014) (b) Gastro-intestinal and segmental transit times: a radiographic measure of the transit time of stool with the abdomen
Bibliographic citation/
Study type/ Level of
evidence
Sample
characteristics
Intervention (I) Comparison
(C)
Length of study Outcome measures
Effect size (ES)
(Intervention-comparison)
Emly, M., Cooper, S. & Vail, A. (2015). Colonic Motility in Profoundly Disabled People – A comparison of massage and laxative therapy in the management of
constipation. Physiotherapy, 84(4), 178-183.
- Emily et al. (1998)
- Randomized
cross-over trial
- 1- ---(a)
- Mean age: 42.25
- 18 (56.3%) female
- Cerebral palsy or
genetic condition with
symptoms of
abnormal muscle tone
- Regular use of
laxatives/ enemas for
at least 12 months in
prior
-Two interventions
(20-min massage
conducted 5 times/ week
for 7 weeks, and usual
laxative regimen for 7
weeks with 1 week of
wash-out period between
interventions)
- Group 1: massage first,
then laxative
(n = 15)
-Group 2:
Laxative first, then
massage
(n = 16)
Using
subjects’
baseline
information
for
comparison
-18 weeks in total
- Week 0-1
(Baseline/ pre
intervention)
- Week 2-9
(Phase A:
intervention)
-Week 10
(Wash-out period)
-Week 11-18
(Phase B:
intervention)
Primary:
(1) Gastro-intestinal
and segmental
transit times
Secondary:
(2) Enema
requirement
(3) Stool frequency
(4) Stool size
(5) Stool consistency
(6) Well-being
Group 1:
(1) -35
(2)-(6) Cannot determine
(No baseline data for
comparison)
Group 2:
(1) -71
(2)-(6) Cannot determine
(No baseline data for
comparison)
[For both groups, ES were
large using colonic transit
time for outcome
measure]
57
57
Appendix 8: Table of Evidence E
(a) Scottish Intercollegiate Guidelines Network (2014)
(b) For making a diagnosis of constipation
(c) A diary developed by general practitioners from Wroclaw, Poland to record the bowel movement and/or experienced straining
Bibliographic citation/
Study type/ Level of
evidence
Sample characteristics Intervention (I) Comparison
(C)
Length of study Outcome measures
Effect size (ES)
(Intervention vs
control/ comparison
of p value)
Kassolik, K., Andrzejewski, W., Wilk, I., Brzozowski, M., Voyce, K., Jaworska-Krawiecka, E., et al. (2015). The effectiveness of massage based on the tensegrity
principle compared with classical abdominal massage performed on patients with constipation. Archives of Gerontology and Geriatrics, 61, 202-211.
- Kassolik et al. (2015)
- Randomized control
trial
- 1+ ---(a)
- Mean age: 57.8yrs
- 18 (89.6%) female
- Fulfilled the Rome III
criteria for constipation
---(b)
-Received 6
massage sessions
based on tensegrity
principle with 2
sessions/ week for 3
consecutive weeks
(n = 15)
Received 6
massage sessions
of classical
massage with 2
sessions/ week for
3 consecutive
weeks
(n = 14)
-3 weeks in total
- Week 0
(Baseline/ pre
intervention)
- Week 1-3
(intervention)
-Week 3
(Questionnaire
administered)
Diary ---(c)
(1) Number of bowel
movement
(2) Straining experience
(1) 1.87 vs 0.57
[p=0.01223]
[ES is large and result
is statistically
significant]
(2) -6 vs -1 [p=0.049]
[ES is large and
result is statistically
significant]
58
58
Appendix 9: Scottish Intercollegiate Guidelines Network (SIGN) Checklist A
S I G N
Methodology Checklist 2: Controlled
Trials Study identification (Include author, title, year of publication, journal title, pages)
McClurg, D., Hagen, S. Hawkins, S. & Lowe-Strong, A. (2011). Abdominal massage for the alleviation of
constipation symptoms in people with multiple sclerosis: a randomized controlled feasibility study.
Multiple Sclerosis Journal, 17(2), 223-233.
Guideline topic: Abdominal massage for the alleviation of
constipation symptoms in people with multiple sclerosis
Key Question No: Reviewer:
Chan Ka Man
Before completing this checklist, consider:
1. Is the paper a randomised controlled trial or a controlled clinical trial? If in doubt, check the study
design algorithm available from SIGN and make sure you have the correct checklist. If it is a
controlled clinical trial questions 1.2, 1.3, and 1.4 are not relevant, and the study cannot be rated
higher than 1+
2. Is the paper relevant to key question? Analyse using PICO (Patient or Population Intervention
Comparison Outcome). IF NO REJECT (give reason below). IF YES complete the checklist.
Reason for rejection: 1. Paper not relevant to key question 2. Other reason (please specify):
Section 1: Internal validity
In a well conducted RCT study…
Does this study do it?
1.1 The study addresses an appropriate and clearly focused question.
Yes
Can’t say
No
1.2 The assignment of subjects to treatment groups is randomised. Yes
Can’t say
No
1.3 An adequate concealment method is used.
Yes
Can’t say
No
59
59
1.4 The design keeps subjects and investigators ‘blind’ about treatment
allocation.
Yes
Can’t say
No
1.5 The treatment and control groups are similar at the start of the trial. Yes
Can’t say □
No
1.6 The only difference between groups is the treatment under
investigation.
Yes
Can’t say
No
1.7 All relevant outcomes are measured in a standard, valid and reliable
way.
Yes
Can’t say
No
1.8 What percentage of the individuals or clusters recruited into each
treatment arm of the study dropped out before the study was
completed?
Percentage of drop out
= 1/30 x 100% = 3.33%
1.9 All the subjects are analysed in the groups to which they were
randomly allocated (often referred to as intention to treat analysis).
Yes
Can’t say
No
Does not apply
1.10 Where the study is carried out at more than one site, results are
comparable for all sites.
Yes
Can’t say
No
Does not apply
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1
How well was the study done to minimise bias?
Code as follows:
High quality (++)
Acceptable (+)
Low quality (-)
Unacceptable – reject 0
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the
statistical power of the study, are you certain
No. Although the study is RCT and could fulfil
most of the items on this checklist, due to the
relatively small sample size (n = 30), I am not
60
60
that the overall effect is due to the study
intervention?
certain if there is direct relationship between the
intervention and overall effect, since some of the
data are not statistically significant (p > 0.05).
2.3 Are the results of this study directly applicable to
the patient group targeted by this guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own assessment of the
study, and the extent to which it answers your question and mention any areas of uncertainty raised
above.
The study showed that the intervention had a potential positive effect on relief of the symptoms of
constipation, and the authors also indicated the feasibility of further study in relieving constipation in
patients with MS. However, due to the small sample size of this study and inadequate blinding, the
generalizability and objectivity of the study is decreased.
61
61
Appendix 10: Scottish Intercollegiate Guidelines Network (SIGN) Checklist B
S I G N
Methodology Checklist 2: Controlled
Trials Study identification (Include author, title, year of publication, journal title, pages)
La m̈a°s, K., Lindholm, L., Engstro m̈, B. & Jacobsson, C. (2010). Abdominal massage for people with
constipation: a cost utility analysis. Journal of Advanced Nursing, 66 (8), 1719-1729.
Guideline topic: Abdominal massage to increase
health-related quality of life and as a cost-effective method
in managing constipation
Key Question No: Reviewer:
Chan Ka Man
Before completing this checklist, consider:
1. Is the paper a randomised controlled trial or a controlled clinical trial? If in doubt, check the study
design algorithm available from SIGN and make sure you have the correct checklist. If it is a
controlled clinical trial questions 1.2, 1.3, and 1.4 are not relevant, and the study cannot be rated
higher than 1+
2. Is the paper relevant to key question? Analyse using PICO (Patient or Population Intervention
Comparison Outcome). IF NO REJECT (give reason below). IF YES complete the checklist.
Reason for rejection: 1. Paper not relevant to key question 2. Other reason (please specify):
Section 1: Internal validity
In a well conducted RCT study…
Does this study do it?
1.1 The study addresses an appropriate and clearly focused question.
Yes
Can’t say
No
1.2 The assignment of subjects to treatment groups is randomised. Yes
Can’t say
No
1.3 An adequate concealment method is used.
Yes
Can’t say
No
62
62
1.4 The design keeps subjects and investigators ‘blind’ about treatment
allocation.
Yes
Can’t say
No
1.5 The treatment and control groups are similar at the start of the trial. Yes
Can’t say □
No
1.6 The only difference between groups is the treatment under
investigation.
Yes
Can’t say
No
1.7 All relevant outcomes are measured in a standard, valid and reliable
way.
Yes
Can’t say
No
1.8 What percentage of the individuals or clusters recruited into each
treatment arm of the study dropped out before the study was
completed?
Percentage of drop out
= 8/58 x 100% = 13.8%
1.9 All the subjects are analysed in the groups to which they were
randomly allocated (often referred to as intention to treat analysis).
Yes
Can’t say
No
Does not apply
1.10 Where the study is carried out at more than one site, results are
comparable for all sites.
Yes
Can’t say
No
Does not apply
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1
How well was the study done to minimise bias?
Code as follows:
High quality (++)
Acceptable (+)
Low quality (-)
Unacceptable – reject 0
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the
statistical power of the study, are you certain
Yes
63
63
that the overall effect is due to the study
intervention?
2.3 Are the results of this study directly applicable to
the patient group targeted by this guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own assessment of the
study, and the extent to which it answers your question and mention any areas of uncertainty raised
above.
Abdominal massage as a cost-effective way in managing constipation, with statistically significant
results obtained in the study. However, the small sample size and non-blinding nature decrease the
generalizability of the study. As the study aimed to determine if the massage therapy increase
health-related quality of life, the EQ-5D profile used consisted of items may be more compatible to
symptoms in irritable bowel symptom (IBS) than in constipation.
64
64
Appendix 11: Scottish Intercollegiate Guidelines Network (SIGN) Checklist C
S I G N
Methodology Checklist 2: Controlled
Trials Study identification (Include author, title, year of publication, journal title, pages)
La¨ma˚s, K., Lindholm, L., Stenlund, H., Engstro¨ma, B. & Jacobsson, C. (2009). Effects of abdominal
massage in management of constipation - A randomized controlled trial. International Journal of Nursing
Studies, 46, 759-767.
Guideline topic: Abdominal massage in management of
constipation
Key Question No: Reviewer:
Chan Ka Man
Before completing this checklist, consider:
1. Is the paper a randomised controlled trial or a controlled clinical trial? If in doubt, check the study
design algorithm available from SIGN and make sure you have the correct checklist. If it is a
controlled clinical trial questions 1.2, 1.3, and 1.4 are not relevant, and the study cannot be rated
higher than 1+
2. Is the paper relevant to key question? Analyse using PICO (Patient or Population Intervention
Comparison Outcome). IF NO REJECT (give reason below). IF YES complete the checklist.
Reason for rejection: 1. Paper not relevant to key question 2. Other reason (please specify):
Section 1: Internal validity
In a well conducted RCT study…
Does this study do it?
1.1 The study addresses an appropriate and clearly focused question.
Yes
Can’t say
No
1.2 The assignment of subjects to treatment groups is randomised. Yes
Can’t say
No
65
65
1.3 An adequate concealment method is used.
Yes
Can’t say
No
1.4 The design keeps subjects and investigators ‘blind’ about treatment
allocation.
Yes
Can’t say
No
1.5 The treatment and control groups are similar at the start of the trial. Yes
Can’t say □
No
1.6 The only difference between groups is the treatment under
investigation.
Yes
Can’t say
No
1.7 All relevant outcomes are measured in a standard, valid and reliable
way.
Yes
Can’t say
No
1.8 What percentage of the individuals or clusters recruited into each
treatment arm of the study dropped out before the study was
completed?
Percentage of drop out
= 8/58 x 100% = 13.8%
1.9 All the subjects are analysed in the groups to which they were
randomly allocated (often referred to as intention to treat analysis).
Yes
Can’t say
No
Does not apply
1.10 Where the study is carried out at more than one site, results are
comparable for all sites.
Yes
Can’t say
No
Does not apply
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1
How well was the study done to minimise bias?
Code as follows:
High quality (++)
Acceptable (+)
Low quality (-)
Unacceptable – reject 0
66
66
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the
statistical power of the study, are you certain
that the overall effect is due to the study
intervention?
Yes
2.3 Are the results of this study directly applicable to
the patient group targeted by this guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own assessment of the
study, and the extent to which it answers your question and mention any areas of uncertainty raised
above.
The study showed that the intervention had a potential positive effect on relief of the symptoms of
constipation, while no significant differences were found between the intervention and control group
in terms of consistency of stool or stool size. Due to the small sample size, relatively short study
period, inadequate blinding, and self-referred nature of recruitment, the generalizability and
objectivity of the study is decreased.
67
67
Appendix 12: Scottish Intercollegiate Guidelines Network (SIGN) Checklist D
S I G N
Methodology Checklist 2: Controlled
Trials Study identification (Include author, title, year of publication, journal title, pages)
Emly, M., Cooper, S. & Vail, A. (2015). Colonic Motility in Profoundly Disabled People – A comparison of
massage and laxative therapy in the management of constipation. Physiotherapy, 84(4), 178-183.
Guideline topic: Comparing the effect of laxative and
massage therapy in management of constipation
Key Question No: Reviewer:
Chan Ka Man
Before completing this checklist, consider:
1. Is the paper a randomised controlled trial or a controlled clinical trial? If in doubt, check the study
design algorithm available from SIGN and make sure you have the correct checklist. If it is a
controlled clinical trial questions 1.2, 1.3, and 1.4 are not relevant, and the study cannot be rated
higher than 1+
2. Is the paper relevant to key question? Analyse using PICO (Patient or Population Intervention
Comparison Outcome). IF NO REJECT (give reason below). IF YES complete the checklist.
Reason for rejection: 1. Paper not relevant to key question 2. Other reason (please specify):
Section 1: Internal validity
In a well conducted RCT study…
Does this study do it?
1.1 The study addresses an appropriate and clearly focused question.
Yes
Can’t say
No
1.2 The assignment of subjects to treatment groups is randomised. Yes
Can’t say
No
1.3 An adequate concealment method is used.
Yes
Can’t say
No
68
68
1.4 The design keeps subjects and investigators ‘blind’ about treatment
allocation.
Yes
Can’t say
No
1.5 The treatment and control groups are similar at the start of the trial. Yes
Can’t say
No
1.6 The only difference between groups is the treatment under
investigation.
Yes
Can’t say
No
1.7 All relevant outcomes are measured in a standard, valid and reliable
way.
Yes
Can’t say
No
1.8 What percentage of the individuals or clusters recruited into each
treatment arm of the study dropped out before the study was
completed?
Percentage of drop out
= 1/32 x 100% = 3.125%
1.9 All the subjects are analysed in the groups to which they were
randomly allocated (often referred to as intention to treat analysis).
Yes
Can’t say
No
Does not apply
1.10 Where the study is carried out at more than one site, results are
comparable for all sites.
Yes
Can’t say
No
Does not apply
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1
How well was the study done to minimise bias?
Code as follows:
High quality (++)
Acceptable (+)
Low quality (-)
Unacceptable – reject 0
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the
statistical power of the study, are you certain
Yes
69
69
that the overall effect is due to the study
intervention?
2.3 Are the results of this study directly applicable to
the patient group targeted by this guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own assessment of the
study, and the extent to which it answers your question and mention any areas of uncertainty raised
above.
The study aimed to compare the effect of laxative and massage therapy in management of
constipation, and the results found that there was no significant different. However, the study gave an
indication that abdominal massage can relieve constipation by evaluating its effect with the measure
of colon transit time. Blinding is adequate in the study.
70
70
Appendix 13: Scottish Intercollegiate Guidelines Network (SIGN) Checklist E
S I G N
Methodology Checklist 2: Controlled
Trials Study identification (Include author, title, year of publication, journal title, pages)
Kassolik, K., Andrzejewski, W., Wilk, I., Brzozowski, M., Voyce, K., Jaworska-Krawiecka, E., et al. (2015).
The effectiveness of massage based on the tensegrity principle compared with classical abdominal
massage performed on patients with constipation. Archives of Gerontology and Geriatrics, 61, 202-211.
Guideline topic: Investigation of effectiveness of massage
based on the tensegrity principle compared with classical
abdominal massage in managing constipation
Key Question No: Reviewer:
Chan Ka Man
Before completing this checklist, consider:
1. Is the paper a randomised controlled trial or a controlled clinical trial? If in doubt, check the study
design algorithm available from SIGN and make sure you have the correct checklist. If it is a
controlled clinical trial questions 1.2, 1.3, and 1.4 are not relevant, and the study cannot be rated
higher than 1+
2. Is the paper relevant to key question? Analyse using PICO (Patient or Population Intervention
Comparison Outcome). IF NO REJECT (give reason below). IF YES complete the checklist.
Reason for rejection: 1. Paper not relevant to key question 2. Other reason (please specify):
Section 1: Internal validity
In a well conducted RCT study…
Does this study do it?
1.1 The study addresses an appropriate and clearly focused question.
Yes
Can’t say
No
1.2 The assignment of subjects to treatment groups is randomised. Yes
Can’t say
No
1.3 An adequate concealment method is used.
Yes
Can’t say
No
71
71
1.4 The design keeps subjects and investigators ‘blind’ about treatment
allocation.
Yes
Can’t say
No
1.5 The treatment and control groups are similar at the start of the trial. Yes
Can’t say □
No
1.6 The only difference between groups is the treatment under
investigation.
Yes
Can’t say
No
1.7 All relevant outcomes are measured in a standard, valid and reliable
way.
Yes
Can’t say
No
1.8 What percentage of the individuals or clusters recruited into each
treatment arm of the study dropped out before the study was
completed?
Percentage of drop out
= 1/30 x 100% = 3.33%
1.9 All the subjects are analysed in the groups to which they were
randomly allocated (often referred to as intention to treat analysis).
Yes
Can’t say
No
Does not apply
1.10 Where the study is carried out at more than one site, results are
comparable for all sites.
Yes
Can’t say
No
Does not apply
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1
How well was the study done to minimise bias?
Code as follows:
High quality (++)
Acceptable (+)
Low quality (-)
Unacceptable – reject 0
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the
statistical power of the study, are you certain
Yes
72
72
that the overall effect is due to the study
intervention?
2.3 Are the results of this study directly applicable to
the patient group targeted by this guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own assessment of the
study, and the extent to which it answers your question and mention any areas of uncertainty raised
above.
The study showed that the massage based on tensegrity principle had a greater effect on relief of
constipation in terms of increased bowel movement and reduced straining experience, when
compared with that of classical massage, while the study also demonstrated a positive effect of the
classical massage on managing constipation which was also statistically significant. However, due to
the small sample size, the generalizability and objectivity of the study is reduced.
73
73
Appendix 14: Timeline of an evidence-based program to prevent constipation in patients after having hip surgery
Event \ month 1 2 3 4 5 6 7 8 9 10 11 12
Preparation Proposal writing
Getting approval
Preparation of
materials & staff
training
Implementation Pilot study
Formal
implementation
Evaluation Data collection &
analysis
74
74
Appendix 15: Table showing set-up and operational cost in terms of personnel
salary of the evidence-based abdominal massage therapy
Nurse
specialist
RN (Team
member)
RN(Non-team
member)
Number 1 7 21
Hourly Salary (HKD)* $259 $163 $163
Set-up cost
Hour used Meeting and preparation 8 8 /
Briefing
session
Organizer 1.5 1.5 /
Attendant / / 1.5
Training
session
Trainer 1.5 1.5 /
Trainee / / 1.5
Subtotal (HKD) $2849 $12551 $10269
Operational cost (per year)
Working hour
(per year)
Application of massage / / /
Data collection and analysis 4x 52 = 208 4 x 7 x 52 = 1456 0.5 x 5.6 x 312 =
873.6
Subtotal (HKD) $53872 $237328 $142396.8
Total cost of running the program for one
year (HKD)
$459265.8
75
75
Appendix 16: Table showing the cost to be saved from implementation of
program per year
Cost to be saved per year
Average duration of
hospital stay for
constipation (day)
5.6
Cost of hospitalization in
general ward per day
(HKD)
$4680
Number of patients
benefit from the program
per year
384
Total cost (HKD) 5.6 x $4680 x 312 =
$10,063,876
76
76
Appendix 17: Grades of recommendations
Scottish Intercollegiate Guidelines Network (2014)
Grade Statement
A At least one meta-analysis, systematic review, or RCT rate as
1++, and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as
1+, directly applicable to the target population, and
demonstrating overall consistency of results
B A body of evidence including studies rated as 2++, directly
applicable to the target population, and demonstrating overall
consistency of results; or
Extrapolated evidence from studies rated 1++ or 1+
C A body of evidence including studies rated as 2+, directly
applicable to the target population and demonstrating overall
consistency of results; or
Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
77
77
Appendix 18: Flowchart of the communication plan within the O&T Department
Proposer
Nurse specialist
Organizing committee
COS DOM
Ward manager
Surgeon and Nurse
Communication with targeted patients and their relatives
Endorsement of proposed care
Identify needs & provide evidence
Gather information
Considered appropriate
Agree for implementation
Not agree
Amendment
Agree for implementation
Amendment
Not agree
Not agree
Not agree
Agree for being the instructor of massage therapy
78
78
Appendix 19: Self-designed patient referral form for abdominal massage
Referral Form – Abdominal Massage Program to Prevent Constipation
Case No.: __________________________________________________________
Diagnosis: _________________________________________________________
Name of operation: ____________________ Date of operation: ___________
Date of Referral: ______________________ Referred by: ________________
Referral checklist
Inclusion criteria
[Included if ALL criteria are met]
Exclusion criteria
[Excluded if either one is met]
Aged 18 or above
Undergone hip surgery
No indication of constipation *
With cognitive impairment
With hearing problem
Speak language other than Cantonese
and English
Presence of abdominal mass
Received radiotherapy within six
weeks
* Rome II criteria for functional constipation
(To make a diagnosis of constipation, the patient must report two or more of the
following criteria.)
- Straining in > 25% defecations
- Lumpy or hard stools in > 25% defecations
- Sensation of incomplete evacuation in > 25% defecations
- Sensation of anorectal obstruction / blockade in > 25% defecations
- Manual manoeuvres to facilitate > 25% defecations
- < 3 defecations per week
Patient’s gum label
79
79
Appendix 20: Self-designed nursing assessment form for abdominal massage
program
Nursing Assessment Form –
Abdominal Massage Program to Prevent Constipation
Age: ______________________ Gender: Male Female
Marital status: ______________ Current / last occupation: ________________
Diagnosis: _________________ Past medical history: ___________________
Pre-morbid mobility:
Independent Ambulatory with aids/ assistance
Chair-bound Bedridden
Current use of opiate analgesics: Yes No
If yes, please specify:___________________
No. of bowel movement (per week): __________________________________
Current use of laxative:
Yes No
If yes, please specify:___________________
Patient’s gum label
80
80
Appendix 21(a): SF-12 Health Survey (English version)
SF-12 Health Survey (Standard)
Instruction: This questionnaire will ask about your perception and opinion towards the
health status of your own. Please answer all the questions by ticking the
appropriate boxes.
Date: _______________________ Name: ____________________ (optional)
Q1. In general, you would say your health to be:
Excellent Very good Good Fair Bad
The following two questions are about activities you might do during a typical day.
Does your current health status limit you in these activities? If so, to what extent?
Q2. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling,
playing golf or practicing Tai Chi:
Yes, limited a lot Yes, limited a little No, not limited at all
Q3. Climbing several flights of stairs:
Yes, limited a lot Yes, limited a little No, not limited at all
During the past 4 weeks, have you had any of the following problems with your work
or other usual activities as a result of your physical health?
Q4. Accomplished less than you expect:
Yes No
Q5. Were limited in the kind of work or activities:
Yes No
81
81
During the past 4 weeks, were you limited in the kind of work you do or other usual
activities as a result of any emotional disturbances (e.g. feeling depressed or worried)?
Q6. Accomplished less than you expect:
Yes No
Q7. Being less careful as usual:
Yes No
Q8. During the past 4 weeks, how much did pain interfere with your usual work
(including both domestic and non-domestic work)?
Not at all A little bit Moderately Quite a lot Extremely
The following questions are about how you feel and react during the past 4 weeks. For
each question, please choose the answer that comes closest to the way you have been
feeling. How much of the time during the past 4 weeks?
Q9. Did you feel calm and peaceful?
All of
the time
Most of
the time
A good
bit of the
time
Some of
the time
A little
of the time
None of
the time
Q10. Did you feel energetic?
All of
the time
Most of
the time
A good
bit of the
time
Some of
the time
A little
of the time
None of
the time
Q11. Have you felt downhearted and blue?
All of
the time
Most of
the time
A good
bit of the
time
Some of
the time
A little
of the time
None of
the time
Q12. During the past 4 weeks, how much time did your physical health or emotional
problems interfered with your social activities (e.g. visiting friends, relatives, etc.)?
All of the
time
Most of the
time
Some of the
time
None of
the time
None of
the time
82
82
Appendix 21(b): SF-12 Health Survey (Chinese version)
生活品質量表-SF-12 (標準)
指示：這份問卷會問一些關於你健康狀況的意見，這些資料幫助我們了解及記錄
你的健康狀況及你日常生活的狀況。請回答每一條問題。
問卷填寫日期：___________________ 姓名：__________________(非必須的)
1.大致上，你覺得你的健康怎樣：
十分好 很好 好 不太好 差
以下的問題是你通常在一天內會做好的事情，你現在的健康狀況是否有阻礙你做
這些事情﹖如有，程度又多大呢﹖
2. 中等程度的活動，例如搬一張桌子，推一部吸塵器，打保齡球，打哥爾夫或
打太極拳﹖
有很大阻礙 有些少阻礙 沒有阻礙
3. 步行上幾層樓梯
有很大阻礙 有些少阻礙 沒有阻礙
在過去四星期內，有沒有因為你的身體健康狀況令你在工作上或其他慣常活動上
出現以下的困難﹖
4. 完成的工作比想像中少：
是 否
5. 可以做的工作或活動的種類有限：
是 否
83
83
在過去四星期內，有沒有因為你的情緒上的困擾（例如抑鬱或擔憂）令你在工作
上或其他慣常活動上出現以下的困難﹖
6. 完成的工作比想像中少：
是 否
7. 沒有比平時做得那麼小心：
是 否
8. 在過去四星期內，痛楚對你慣常的工作（包括家務非家務性的工作）影響有
多少﹖
完全沒有 些少 有 頗多 十分多
以下題目是關於你在過去四星期內的感受及對事情的觀感，請在每一題目選擇最
接近你的感覺的答案。在過去四星期內，你有多少時間是：
9. 感到平靜及和諧呢﹖
所有時間
大部分時間
頗多時間
有一些時間
有少許時間
從沒有
10. 感到充滿精力呢﹖
所有時間
大部分時間
頗多時間
有一些時間
有少許時間
從沒有
11. 感覺傷心及憂心呢﹖
所有時間
大部分時間
頗多時間
有一些時間
有少許時間
從沒有
12. 在過去四星期內，有多少時間因為你身體健康狀況或情緒問題而令你的社交
活動影響（例如探訪親友）﹖
所有時間 大部分時間 有一些時間 有少許時間 從沒有
84
84
Appendix 22(a) : Self-designed questionnaire for patients (English version)
Questionnaire for the “Evidence-based guideline of using abdominal massage to
prevent constipation” for patients undergone hip surgery
Thank you for your participation in the program. Your feedback for the EBP guideline
and intervention is important for improvement of all aspect of the program. Please
complete the questionnaire form based on your own perspectives.
Date: _______________________ Name: ____________________ (optional)
From a patient’s point of view, how would you rate the following questions? Please
put a “” to indicate the most appropriate column for each question.
Q1. Do you think the daily abdominal massage is adequate?
Very adequate Adequate Neutral Inadequate Very inadequate
Q2. Do you think nurses provide adequate care for prevention of constipation during
your hospital stay?
Very adequate Adequate Neutral Inadequate Very inadequate
Q3. Do you think nurses have adequate knowledge and in providing care for
prevention of constipation?
Very adequate Adequate Neutral Inadequate Very inadequate
Q4. Do you think nurses are skillful to perform abdominal massage for prevention of
constipation?
Very skillful Skillful Neutral Unskillful Very unskillful
85
85
Q5. How do you rate the effectiveness of the abdominal massage program in
prevention of constipation?
Very effective Effective Neutral Ineffective Very ineffective
Q6. How do you rate your overall level of satisfaction to the abdominal massage
program?
Excellent Good Satisfactory Fair Poor
Q7. What are your comments or suggestions for further improvement of the
abdominal massage program in prevention of constipation?
__________________________________________________________________
__________________________________________________________________
86
86
Appendix 22(b): Self-designed questionnaire for patients (Chinese version)
預防便祕腹部按摩計劃問卷調查
感謝你參與「預防便祕腹部按摩計劃」， 你寶貴的意見對於改善計劃及提升服務
質素是非常重要的。請完成此問卷，多謝你的參與和合作。
問卷填寫日期：___________________ 姓名：__________________(非必須的)
請以病人的角度評價以下各項目.，請以號表示出你的選擇.。
1. 你認為每日一次的腹部按摩足夠嗎﹖
非常足夠 足夠 無意見 不足夠 非常不足夠
2. 在你住院期間，你認為護士在預防便祕方面，有給予足夠的護理嗎﹖
非常足夠 足夠 無意見 不足夠 非常不足夠
3. 你認為護士有足夠的知識為你提供預防便祕的護理嗎﹖
非常足夠 足夠 無意見 不足夠 非常不足夠
4. 你認為護士有熟練的技巧為你提供預防便祕的腹部按摩嗎﹖
非常熟練 熟練 無意見 不熟練 非常不熟練
5. 你認為腹部按摩能有效預防便祕嗎﹖
非常有效 有效 無意見 不太有效 完全無效
6. 整體而言, 你對我們提供的預防便祕腹部按摩計劃滿意嗎﹖
非常好 好 滿意 尚可 差
7. 最後，你對預防便祕腹部按摩計劃有沒有其他意見作日後改善之用﹖
__________________________________________________________________
87
87
Appendix 23: Self-designed staff satisfaction survey on the staff training and
pilot study
Staff Satisfaction Survey on the Staff Training and Pilot Study of Abdominal Massage
Program
Date: ____________________________
Name: ____________________(optional) Rank: _______________________
This questionnaire inquires about your level of satisfaction about the staff training and
the pilot study of the abdominal massage program. Please indicate your ratings of the
following presentation by choosing the appropriate number based on your own
opinion, using a scale from 1 (least agree) to 5 (most agree).
Part I:
Briefing session
Statement Least
agree
Neutral Most
agree
Q1 The aim and objectives were clear to
understand.
1 2 3 4 5
Q2 The content was organized and easy
to follow.
1 2 3 4 5
Q3 The content was relevant and useful. 1 2 3 4 5
Q4 The speaker was knowledgeable of
the subject matter.
1 2 3 4 5
Q5 The presentation skill of speaker was
satisfactory.
1 2 3 4 5
Q6 The pace of presentation was
appropriate
1 2 3 4 5
Q7 The duration was appropriate. 1 2 3 4 5
Q8 The venue was suitable. 1 2 3 4 5
88
88
Part II:
Training Session
Statement Least
agree
Neutral Most
agree
Q9 The aim and objectives were clear to
understand.
1 2 3 4 5
Q10 The content was organized and easy
to follow.
1 2 3 4 5
Q11 The content was relevant and
practical.
1 2 3 4 5
Q12 The trainer was knowledgeable of
the subject matter.
1 2 3 4 5
Q13 The presentation skill of trainer was
satisfactory.
1 2 3 4 5
Q14 The pace of presentation was
appropriate
1 2 3 4 5
Q15 The duration was appropriate. 1 2 3 4 5
Q16 The venue was suitable. 1 2 3 4 5
Part III:
Pilot study
Statement Least
agree
Neutral Most
agree
Q17 The statement of the guideline is
clear.
1 2 3 4 5
Q18 The content of the guideline is
relevant.
1 2 3 4 5
Q19 The content of the guideline was
based on credible and up-to-date
information.
1 2 3 4 5
Q20 I received adequate support to use
the guideline.
1 2 3 4 5
Q21 This guideline is user-friendly and
easy to follow.
1 2 3 4 5
Q22 The duration of pilot study is
appropriate.
1 2 3 4 5
Q23 The budget plan for pilot study was
appropriate.
1 2 3 4 5
Q24 Resources like personnel and
equipment were sufficient.
1 2 3 4 5
89
89
Appendix 24: Self-designed audit form for abdominal massage
Audit form for abdominal massage
[Please stick patient’s gum label below; inform the organizing committee upon patient discharge]
Patient’s gum label Patient’s discharge date:
____________________
1. Eligible patient is selected.
2. Massage is started on post-operative Day 2.
3. Abdominal massage is performed daily.
4. Each massage session lasts for 10-20 minutes.
5. Proper documentation is done after each session.
Remarks: _________________________________
Yes
Yes
Yes
Yes
Yes
No Reason: ______
No Reason: ______
No Reason: ______
No Reason: ______
No Reason: ______
Patient’s gum label Patient’s discharge date:
____________________
1. Eligible patient is selected.
2. Massage is started on post-operative Day 2.
3. Abdominal massage is performed daily.
4. Each massage session lasts for 10-20 minutes.
5. Proper documentation is done after each session.
Remarks: _________________________________
Yes
Yes
Yes
Yes
Yes
No Reason: ______
No Reason: ______
No Reason: ______
No Reason: ______
No Reason: ______
Patient’s gum label Patient’s discharge date:
____________________
1. Eligible patient is selected.
2. Massage is started on post-operative Day 2.
3. Abdominal massage is performed daily.
4. Each massage session lasts for 10-20 minutes.
5. Proper documentation is done after each session.
Remarks: _________________________________
Yes
Yes
Yes
Yes
Yes
No Reason: ______
No Reason: ______
No Reason: ______
No Reason: ______
No Reason: ______
90
90
Appendix 25: Self-designed record form for abdominal massage
Abdominal Massage Record
Please kindly complete the record form after each massage session.
Withhold the abdominal massage program once diarrhea/ patient intolerance occurs.
Procedure: 1. Start the program after breakfast.
2. Perform massage daily in a clock-wise direction for 10-20 minutes.
3. Continue current use of laxatives if prescribed.
4. If no/ poor result, perform digital simulation on the next day as
well.
5. If still no/ poor result ≥ 3 days or with fecal impaction indicated,
perform digital evacuation.
Date Start
Time
End
Time
Laxative
use (Y/N)
Fecal
Elimination
Time
Fecal
Nature/
Amount
Remarks
Patient’s gum label
91
91
Appendix 26: Self-designed questionnaire for nurses in O&T Department
Questionnaire for the “Evidence-based guideline of using abdominal massage to
prevent constipation for patients undergone hip surgery” for nurses in O&T
Department
Thank you for your participation in the program. Your feedback for the EBP guideline
and intervention is important for improvement of all aspect of the program. Please
complete the questionnaire form based on your own perspectives.
Date: ______________________
Name: _______________(optional) Rank: ________________
From a nurse’s point of view, how would you rate the following questions? Please put
a “” to indicate the most appropriate column for each question.
Q1. How do you rate the effectiveness of the guideline of using abdominal massage
for preventing constipation in patients undergone hip surgery?
Very effective Effective Neutral Ineffective Very ineffective
Q2. The briefing and training sessions provided by the organizing committee for
implementation of the abdominal massage was useful.
Strongly agree Agree Neutral Disagree Strongly disagree
Q3. Are you confident to perform abdominal massage after attending the two training
sessions provided by the nurse specialist?
Very confident Confident Neutral
A little bit confident Not confident at all
Q4. The skills and knowledge to prevent constipation by performing abdominal
massage was enhanced after the implementation of program.
Strongly agree Agree Neutral Disagree Strongly disagree
92
92
Q5. A sense of job satisfaction was developed after the implementation of the
abdominal massage program.
Strongly agree Agree Neutral Disagree Strongly disagree
Q5. How do you rate the feasibility of the abdominal massage program in the future?
Very feasible Feasible Neutral Not very feasible Infeasible
Q6. How do you rate the workload that you encountered in the implementation of the
abdominal massage program?
Strongly acceptable Acceptable Neutral
Unacceptable Strongly unacceptable
Q7. Do you support the continuum of the proposed massage therapy after the one
year- implementation?
Strongly support Support Neutral Oppose Strongly oppose
Q8. In conclusion, how do you rate the evidence-based practice guideline of
abdominal massage in prevention of constipation?
Excellent Good Satisfactory Fair Poor
Q9. What are your comments or suggestions for further improvement of this
evidence-based practice guideline of abdominal massage in prevention of
constipation?
_____________________________________________________________________
_________________________________________________
Q10. Do you encounter any problems or difficulties during the implementation of the
abdominal massage program? If yes, please specify.
___________________________________________________________
___________________________________________________________
93
93
Reference
Ayas ̧S., Leblebici, B., So ̈zay, S., Bayramog˘ lu, M. & Niron E. A. (2006).
The effect of abdominal massage on bowel function in patients with spinal cord
injury. American Journal of Physical Medicine & Rehabilitation, 85, 951–955.
Carlson, N.S. (2015). Current Resources for Evidence-Based Practice,
November/December 2015. Journal of Obstetric, Gynecologic & Neonatal
Nursing, 44(6), 751-757.
Causes of Constipation. (2014). Retrieved December 7, 2015, from
http://dictionary.sensagent.com/Defecation/en-en/
Chan, Y.K., Kwan, C.P., Yuen, H., Yeung, Y.W., Lai, K.C., Wu, J., et al. (2004).
Normal colon transit time in healthy Chinese adults in Hong Kong.
Journal of Gastroenterology and Hepatology, 19, 1270-1275.
Connor, M., Hunt, C., Lindley, A. & Adams, J. (2014). Using abdominal massage in
bowel management. Nursing Standard, 28(45), 37-42.
Cope, D. G. (2015). Conducting Pilot and Feasibility Studies. Oncology Nursing
Forum, 42(2), 196-197.
94
94
de Velde, S.V., Roshanov, P., Kortteisto, T., Kunnamo, I., Aertgeerts, B., Vandvik,
P.O., et al. (2016). Tailoring implementation strategies for evidence-based
recommendations using computerised clinical decision support systems: protocol
for the development of the GUIDES tools. Implementation Science, 11(29), 1– 8.
Defecation. (2012). Retrieved December 7, 2015, from
http://dictionary.cambridge.org/dictionary/english-chinese-traditional/defecate?q
=defecation
Diagnosing constipation. (2014). Retrieved December 8, 2015, from
http://www.nhs.uk/Conditions/Constipation/Pages/Diagnosis.aspx
Doreen, M., SuzanneH., Stanley, H. & Andrea, L.S. (2013). Abdominal massage for
the alleviation of constipation symptoms in people with multiple sclerosis:
a randomized controlled feasibility study. Multiple Sclerosis Journal, 17(2),
223-233.
Emly, M., Cooper, S. & Vail, A. (2015). Colonic Motility in Profoundly Disabled
People – A comparison of massage and laxative therapy in the management of
constipation. Physiotherapy, 84(4), 178-183.
Ernst, E. (1990). Abdominal Massage Therapy for Chronic Constipation:
A Systematic Review of Controlled Clinical Trials. Research in
ComplementaryMedicine, 6, 149-151.
95
95
Faleiros, F. & de Paula, E.D.R. (2013). Constipation in patients with quadriplegic
cerebral palsy: intestinal reeducation using massage and a laxative diet.
Retrieved February 16, 2016, from
http://dx.doi.org/10.1590/S0080-623420130000400010
Fees and Charge (2015). Retrieved February 14, 2016, from
http://www.ha.org.hk/visitor/ha_visitor_index.asp?Content_ID=10045&Lang=
ENG&Dimension=100&Parent_ID=10044&Ver=HTML
Finfgeld-Connett, D. (2010). Generalizability and transferability of meta-synthesis
research findings. Journal of Advanced Nursing, 66(2), 246-254.
Gary, M. (2014). Managing constipation in primary care. Primary Health Care, 24(5),
18-22.
G*Power: Statistical Power Analyses for Windows and Mac. (2012). Retrieved
May 7, 2016, from http://www.gpower.hhu.de/en.html
Hornby, A. S. (Ed.). (1994). Oxford Advanced Learner’s English-Chinese Dictionary
(4th ed.). Oxford University Press.
Jaegers, L., Dale, A.M., Weaver, N., Buchholz, B., Welch, L. & Evanoff, B. (2014).
Development of a Program Logic Model and Evaluation Plan for a Participatory
Ergonomics Intervention in Construction. American Journal of Industrial
Medicine, 57, 351-361.
96
96
Kassolik, K., Andrzejewski, W., Wilk, I., Brzozowski, M., Voyce, K.,
Jaworska-Krawiecka, E., et al. (2015). The effectiveness of massage based on the
tensegrity principle compared with classical abdominal massage performed on
patients with constipation. Archives of Gerontology and Geriatrics, 61, 202-211.
Keogh, J. (1997). Professionalization of nursing: development, difficulties and
solutions. Journal of Advanced Nursing, 25(2), 302-308.
Kitson, A.L. , & Harvey, G. (2016). Methods to Succeed in Effective Knowledge
Translation in Clinical Practice. Journal of Nursing Scholarship, 48(3), 294-302.
Lam, E.T.P, Lam., C.L.K., Fong, D.Y.T. & Huang, W.W. (2013). Is the SF-12
version 2 Health Survey a valid and equivalent substitute for the SF-36 version
2Health Survey for the Chinese? Journal of Evaluation in Clinical Practice, 19,
200-208.
La m̈a° s, K. (2011). Using massage to ease constipation. Nursing Times, 107(4),
26-27.
La m̈a° s, K., Graneheim, U.H. & Jacobsson, C. (2010). Experiences of abdominal
massage for constipation. Journal of Clinical Nursing, 21, 757-765.
La m̈a° s, K., Lindholm, L., Engstro m̈ , B. & Jacobsson, C. (2010). Abdominal
massage for people with constipation: a cost utility analysis. Journal of
Advanced Nursing, 66(8), 1719-1729.
97
97
La m̈a° s, K., Lindholm, L., Stenlund, H., Engstro m̈ , B. & Jacobsson, C. (2009).
Effects of abdominal massage in management of constipation - A randomized
controlled trial. International Journal of Nursing Studies, 46, 759-767.
Lopez, V. (2003). Critical care nursing research priorities in Hong Kong. Journal of
Advanced Nursing, 43(6), 578-587.
Manojlovich, M., Squires, J.E., Davies, B. & Graham, I. D. (2015). Hiding in plain
sight: communication theory in implementation science. Implementation Science,
10(58), 1-11.
McClurg, D., Hagen, S., Hawkins, S. & Lowe-Strong, A. (2011). Abdominal massage
for the alleviation of constipation symptoms in people with multiple sclerosis:
a randomized controlled feasibility study. Multiple Sclerosis Journal, 17(2),
223-233.
Noiesen, E., Trosborg, I., Bager, L., Herning, M., Lyngby, C. & Konradsen, H. (2013).
Constipation – prevalence and incidence among medical patients acutely
admitted to hospital with a medical condition. Journal of Clinical Nursing,
23, 2295-2302.
Polit, D. F., & Beck, C. T. (2008). Nursing Research: Generating and assessing
evidence for nursing practice (8th ed.). Philadelphia: Lippincott Williams &
Wilkins.
98
98
Preece, J. (2002). Introducing abdominal massage in palliative care for the relief of
constipation. ComplementaryTherapies in Nursing & Midwifery, 8, 101-105.
Schiller, C., Winters, M., Hanson, H. M. & Ashe, M.C. (2013). A framework for
stakeholder identification in concept mapping and health research: a novel
process and its application to older adult mobility and the built environment.
BMC Public Health, 13, 1-9.
Scottish Intercollegiate Guidelines Network. (2014). SIGN 50: a guideline
developer’s handbook. Retrieved November 13, 2015, from
http://www.sign.ac.uk/guidelines/fulltext/50/index.html
Sinclair, M. (2010). The use of abdominal massage to treat chronic constipation.
Journal of Bodywork and Movement Therapies, 1-10.
Smith, M. & Moss, L. (2008). Abdominal massage for constipation in children.
Learning Disability Practice,11(4) 33-36.
Taylor, P. R. E. (1998). Establishing evidence-based practice: issues and implications
in critical care nursing. Intensive and Critical Care Nursing, 14(1), 30-37.
Thomas ̧S. (2014). The hidden cost of constipation. Primary Health Care, 24(6),
31–33.
Trads, M. & Pedersen, P.U. (2015). Constipation and defecation pattern the first 30
days after hip fracture. International Journal of Nursing Practice, 21, 598–604.
99
99
Vision Mission and Values. (2016). Retrieved February 14, 2016, from
http://www.ha.org.hk
Webster, L. R. (2015). Opioid-Induced Constipation. Pain Medicine, 16, 16-21.
Xin, H. W., Fang, Z. C, Zhu, L. M., Xu, T., Fei G. J., Wang, Z. F., et al. (2014).
Diagnosis of functional constipation: Agreement between Rome III and Rome II
criteria and evaluation for the practicality. Journal of Digestive Diseases,
15, 314-320.